Abstract Context Osteoporosis affects over half of older women, but many are not treated. Whether treatment differs between rural and urban areas is unknown. Objective To examine differences in osteoporosis treatment among postmenopausal women living in urban and rural areas of Australia. Methods Women participating in the Australian Longitudinal Study on Women’s Health, a prospective longitudinal cohort study, born between 1946–1951 and with osteoporosis or fractures, were included. Surveys from 2004–2019 were linked to the Pharmaceutical Benefits Scheme (government-subsidised medications), to assess osteoporosis treatment and adherence, comparing geographical areas. Results Of the 4,259 women included (mean age 55.6 years), 1,703 lived in major cities, 1,629 inner regional, 794 outer regional and 133 remote areas. Over the 15-year follow-up, 1,401 (32.9%) women received treatment, including 47.4% of women with osteoporosis and 29.9% with fractures. Women in outer regional and remote areas were less likely to use anti-osteoporosis treatment than those in major cities on univariable analysis (outer regional OR 0.83; 95%CI 0.72, 0.95; remote 0.65; 0.49, 0.86), but this did not remain significant on multivariable analysis. Median duration of use was 10-36 months, adherence varied by treatment type (34-100%) but was not related to incident fractures, and of the women who stopped denosumab, 85% did not receive another consolidating treatment. Conclusion(s) One-third of women with osteoporosis/fractures received treatment, and adherence was low. There was no difference in treatment use between urban and rural areas after adjusting for risk factors, although the specific treatment used, and adherence, differed.