OBJECTIVES: Postmenopausal osteoporosis (PMO) increases the risk of fractures. However, studies have shown that only 20% of German osteoporosis patients receive osteoporosis-specific therapy and for many the adherence to medication is poor.  This study assessed the economic burden of PMO in Germany. METHODS: We applied a systematic review of literature utilizing German based data to quantify osteoporosis-related costs. Our analysis considered both direct costs (inpatient care with/without fracture, rehabilitation, medication, nursing care) and indirect costs (absence from work, early retirement and mortality) attributable to PMO. RESULTS: We identified and analyzed eight cost studies and two administrative databases published between 1999 and 2009. Administrative data sources revealed annual direct and indirect costs of PMO amounting to €2205 million (direct costs: €1697-1879 million). Direct inpatient costs resulting from osteoporosis-related fracture are three times higher than osteoporosis without fracture. Mean hip fracture costs were €7,109-€12,526 and mean costs of vertebral fractures were €4400-€6171. Ambulatory nursing care results in about €132 million per year. Annual inpatient rehabilitation costs add up to €147 million. Annual costs of medication range between €338 million and €664 million. Annual indirect costs due to sickness absence were calculated at €146 million early retirement at €144 million and early death at €34 million. CONCLUSIONS: PMO currently has a considerable economic impact on the German health care system, which will increase with projected demographic changes. Strategies should be aimed at improving the management of this disease.