Purpose of reviewThe purpose of this review is to summarize the evidence on the benefits of menopausal hormone therapy (MHT) for the maintenance of skeletal health, prevention of osteoporosis and related fractures in peri and postmenopausal women.Recent findingsWe will review the impact of estrogen on skeletal health as well as the physiology of bone loss during the perimenopause and postmenopause. We will then elucidate the data that include estrogen alone and combination of MHT to demonstrate that in the absence of contraindication, MHT should be considered as an option for the maintenance of skeletal health both when concomitant menopausal symptoms are present and when not.SummaryIt has been well established that estrogens maintain bone mineral density (BMD) and reduce fracture risk at all sites. However, the most extensively studied form of estrogen with established fracture prevention is oral doses of synthetic estrogens. Due to the reduced risk profile, lower doses of bioidentical oral or transdermal estrogens are often preferred in clinical practice. We will highlight the current data on improvement in BMD and fracture risk reduction, including differences in formulation, dose, and route of delivery, to support a provider in the clinical decision-making process.