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Is estrogen for urinary incontinence good or bad?

Menopausal hormone therapy (MHT) has long been used to improve various postmenopausal symptoms. Until recently, MHT was credited with many benefits well beyond the indications for symptomatic relief of hot flashes, night sweats, and vaginal dryness. Improvement of urinary incontinence (UI) was one of the well-known benefits of MHT in urology practice. 
 
MHT for the treatment of UI was based on assumptions about biological mechanisms, associations of various symptoms with menopause, and small, uncontrolled trials. The lower urinary tract shares a common embryologic origin with the genital tract and the urogenital sinus, and estrogen and progesterone receptors are present in the vaginal epithelium, urethra, and bladder trigone. Reduction of estrogen after menopause leads to significant atrophic changes in the genital tract, which might lead to itching, burning, dryness, and dyspareunia. Coexistent symptoms, including urinary frequency, urgency, UI, and recurrent urinary tract infections, were thought to be related to atrophy of the urinary tract. Because MHT has a beneficial effect on vaginal mucosa, in particular in improving symptoms of atrophic vaginitis, it was suggested that MHT might also improve UI. However, epidemiologic and trial evidence has shown both beneficial and harmful effects of estrogen on UI. 
 
Does MHT really help UI? The evidence and opinions vary widely. The American College of Obstetricians and Gynecologists has stated, “for genitourinary symptoms associated with menopause, estrogen and progestin have been shown to be beneficial.” However, a recent Cochrane review assessing the effects of estrogen for the treatment of UI concluded that treatment with estrogen alone was associated with perceived improvement or cure compared with placebo but that larger trials were needed. Given the recent report that estrogen alone was shown to increase the risk of stroke with no benefit for coronary heart disease, the foundation to support the use of MHT for UI is questioned.