Mesenchymal Stem Cells (MSCs) from bone marrow stroma are capable of differentiating into osteoblasts and adipocytes, among other cell phenotypes. In normal bone marrow osteoblastic and adipocytic cell differentiation occur in favor of bone formation, but this relationship appears disrupted in several bone diseases. In osteoporosis increased bone marrow adipocyte production is counterbalanced by diminished production of osteogenic cells. Since osteoblats and adipocytes originate from a common MSC precursor cell, quantitative and qualitative stem cell defects may underlie the modified number and function of differentiated cells. This review analyzes experimental evidence which describes differences in the osteogenic/adipogenic potentials of human bone marrow MSCs obtained from control and osteoporotic postmenopausal women. The protective effect exerted by locally generated factors, such as estradiol and leptin, on MSCs differentiation was analyzed, because altered bioavailability of these factors may play a part in osteoporosis triggering. Several properties differ among differentiating MSCs from control and osteoporotic donors. Some of these functional differences may be considered to mirror, at the cell level, the detrimental changes displayed in osteoporosis. Osteoporotic MSCs are characterized by increased adipogenic potential, as shown by increased PPARγ protein content and diminished inactivation of the transcription factor, as compared to control cells. Leptin exerts a direct protective activity against adipogenesis only in control cells. In contrast, leptin activity in MSCs from osteoporotic women appears hampered, suggesting that inadequate leptin activity contributes to excessive lipid accumulation in bone marrow.