Osteopenia/osteoporosis (OP) in young adults with beta thalassemia major_(BTM) is a prominent cause of morbidity despite adequate transfusion and iron chelation therapy; the reported frequency of OP varies from 13.6% to 50%, with an additional 45% affected by osteopenia. The pathogenesis of OP in BTM is multifactorial and is related to chronic anaemia with secondary bone marrow expansion, associated endocrinopathies, nutritional deficiencies and genetic factors. These factors lead to OP/osteoporosis by increasing osteoclast activity and impairing osteoblast function. OP is a prominent cause of morbidity in BTM because of the increased risk for vertebral and long bone fractures. Although the bisphosphonates are the most used treatment for osteoporosis in BTM, in some cases there is a poor clinical response with new fractures occurring during treatment; therefore, at least in these patients, we suggest that decreased bone formation is the predominant mechanism of BTM-induced-OP and anabolic treatment could be the most appropriate therapy.