Aromatase inhibitors have become a mainstay in the adjuvant treatment regime in postmenopausal women with hormone-receptor positive breast cancer. While many of these patients have an excellent long-term prognosis, adverse effects on bone represent an emerging complication of aromatase inhibitor treatment, resulting in substantial bone loss and fragility fractures. Treatment approaches to prevent aromatase inhibitor induced bone loss typically consist of an antiresorptive approach with bisphosphonates or the RANKL antibody denosumab. However, different guidelines vary with respect to treatment thresholds, duration and dosing. The choice of antiresorptive regime is further complicated by comorbidities and potential disease modifying effects of individual agents. This review summarizes the evidence of how aromatase inhibitors affect bone health and provides an update of clinical approaches to preserve bone strength in affected women.