Most women and health care providers are knowledgeable about the benefits that estrogen replacement therapy has on the prevention of cardiovascular disease and osteoporosis. What is commonly unknown and under research is the role estrogen plays in maintaining continence. The lower urinary tract shares a common embryologic origin with the female genital organs and is hormonally sensitive. Menopause, either surgical or natural, results in decreased or diminished circulating estrogens that can affect the genitourinary system, causing atrophic symptoms. A comprehensive urinary incontinence workup should include assessment of the vaginal mucosa and treatment of hormone deficiency symptoms such as atrophic vaginitis and urethritis. Risk assessment should be done before hormone replacement therapy is considered.