Menopause changes women’s singing voices

Hi, and welcome to the show where we share the stories of the many who intersect with our healthcare system, but are rarely heard from. My name is Kevin Poe, founder and editor of KevinMD. Today on the show, we have Nancy Bos. She is a vocologist and she's the co-author of the book Singing Through Change. Women's Voices in Midlife, Menopause, and Beyond. And there's an article on KevinMD titled Menopause Changes Women's Singing Voices. Nancy, welcome to the show.

Thank you. It is awesome to be here. Thank you for shining a light on this topic with us.

So we'll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

I'm a, a singer. I taught voice for over 25 years, um, with a focus on voice habilitation. Through a field that is now called vocology. I love the physiology and acoustics of voice, and as I started to look more at my journey into menopause, I started to realize that a lot of women disappear off of the singing scene right around the age of 50. I talked with two other women who had similar concerns and, and deep experiences, Kate Fraser-Neely and Joanne Bosman. Both had already gone through menopause, and we decided that really, there needed to be a book about this topic. And, and in order to write the book, we had to do a lot of research. So we interviewed over 56 women, 56+ women, uh, for this book, um, a qualitative research study to look for what is actually going on for women who identify as singers as they move through midlife and menopause. And then how is that related to aging voice?

Now tell me some of the medical and physiological reasons why someone would need their voice or singing voices to be rehabilitated?

I don't work in the area of rehabilitation. That would be the speech-language pathologists and the laryngologists and other people who are certified in that area. I focus more on habilitation, which is helping women or people of any age avoid getting in trouble. So you may have voice teachers who do not work in habilitation. They may work in where's the money and what do you have to do with your voice in order to get that audience to applaud for you. That would be the opposite of habilitation.

Tell me some of the typical cases that you would see on, I guess, a typical day when you were doing vocology.

Typically, I would see people with some vocal fatigue, but perhaps not any injury yet. I did work with the University of Washington Laryngology Center as one of their referred vocologists for a little while. That would be in the rehabilitation scene. But on the habilitation scene, if you have someone with pre-nodules or somebody with an acid reflux issue, and/or they just come saying, you know, my voice doesn't work right, being able to refer that person on or work with them with vocal function exercises. Function exercises such as the Stemple exercises where you've got high light tones to find out without scoping the client, because that is not within my ability to put a laryngoscope in a throat, without scoping them determine is there something here that needs further attention from the medical field or is it something we can work on through targeted exercises.

And when you do these targeted exercises, how long does it normally take before you see results?

There is a, a few different opinions. Some people say that the, uh, the client or student needs to be scoped before you even talk to them, and other people say give it 6 weeks. I was on the 6-week side because a lot of times, um, vocal, uh, trauma issues are not related to singing, but they are related to their life maybe as a school teacher or somebody who uses their voice loudly all the time, or someone in sports who's making a lot of forceful grunting noises perhaps. And there needs to be time for the person to learn to modify those behaviors, uh, as part of becoming a better singer.

All right, so let's talk about the Kevin MD article that you co-wrote. It's titled Menopause Changes Women's Singing Voices. Now, for those who didn't get a chance to read that article, can you just walk my audience through it and share the story of why you decided to share it?

Absolutely. The big message is that singing voice changes are a symptom of perimenopause and menopause, and they don't show up on any symptom list. But like any menopausal— and also, and like any menopausal symptom, not every woman will experience singing voice changes, but for those who do, especially for those who strongly identify as singers, the changes can be anywhere from upsetting to devastating. So part of the qualitative study was getting the stories from, uh, dozens and dozens of singers and how they journeyed through menopause. Now I want to point out right off the top that menopause can happen to a woman at any point in her adult life. The average age is 51, but a full hysterectomy means instant menopause. Many different kinds of cancer treatments mean temporary or perhaps permanent menopause. And there are women who go into menopause— it's rare— but go into menopause naturally in their late 20s or early 30s. The youngest woman in the book went into menopause at 37. So this is not an aging voice issue, and that's really important to note because now we can isolate this as an estrogen-progesterone-related symptom. In those stories, we found women who their careers were changed because their voices were changing. And because this had never been researched to this degree before, and certainly not written about to this degree, they had no idea, and they took it on as self-blame. And rather than moving forward and seeking answers, because there were very few answers to be found, and I'll go into that in just a second, they would just shut down and perhaps stop singing altogether. One of the stories I share in the article is a woman who's a college professor who's required to do a recital every year for faculty recital day, and her voice gave her so much trouble because of the tension required to make it function in the way that she expected it to. So she had to, in order to get through this, she had to back all the way up to essential technique that we teach to 16 to 18-year-olds and start over again with her new changed voice. That took time, and she needed grace from her profession that she wasn't going to be singing the way she wanted to for a while. But I said I would go back to looking for answers from the medical world. Probably the best people to identify this in the medical world are laryngologists. Laryngologists are board-certified, they're ear, nose, and throat doctors who specialize in the larynx, and they should have a deep understanding of the impact of hormones on the voice. They do not all have that impact, but— that understanding, but a lot of them do. Your basic ENT is perhaps very likely never going to have heard of this before, and the same with OB-GYNs. So it's that board-certified laryngologist is the, is the referral there.

Now give me examples of how specifically women's voices change, uh, during menopause.

I'd be happy to. Um, let me go into, uh, the impact of estrogen and progesterone on the vocal folds. So when estrogen is going along real strong, just fine. It causes suppleness of the vocal folds. It supports the glands. And this is, by the way, straight out of the article. It supports the glands that produce thin mucus that coats the surface of the vocal folds. That's lubrication that's absolutely required for stamina in singing. Estrogen maintains the tone and bulk of skeletal muscles, including the deepest layer of the vocal folds. And it blocks the effects of the androgens, preventing the lowering and thickening of the voice. And it increases oxygenation to the vocal folds. So as that estrogen decreases in perimenopause and then into menopause, the suppleness of the vocal folds will decrease. The mucus that coats the surface of the vocal folds will become thicker and less of it. It maintains the— the estrogen maintains the bulk. Therefore, that muscle in the belly of the vocal folds is going to probably become thinner. Estrogen is gone, so the testosterone, the androgens, can take more action, which can cause a lowering of the speaking pitch up to a half step, a semitone. But It has not been actually studied for how much it lowers the singing voice. And then the decrease of the oxygenation to the vocal folds causes blood vessels and capillaries to be, you know, less. And so the, the whole structure is going to change. In some women, this change is not noticeable. In many women, however, it's the upper range, the, the highest notes of the soprano range that start to suffer. Or in most women's singing, there's a place where we sing in what is commonly called chest voice, and we bridge over into what's called head voice. And we have other terms for it in vocalogy, M1, M2, or cricothyroid dominant and thyroarytenoid dominant. But basically it's that, uh, and you go over that little speed bump, that little hump to get to the thinner voice. For most women, that little area where you have to coordinate between a thyroarytenoid dominant and a cricothyroid dominant sound, that coordination becomes more difficult. So that is one of the biggest issues for singers going through menopause, no matter the age.

Now, what are some of the treatment options that we can do for women in these situations?

Unfortunately, there are very few. Um, with the saliva and mucus issue, um, hydration isn't always the solution for that because that doesn't really help the glands to produce more. And so we talk about nebulizer or a steamer, which can provide up to 20 minutes of moisture on the vocal folds. So if that's helpful, fabulous. Hormone therapy is really the, the best thing that a woman can do for her voice, but that isn't an option for everyone, and some people simply don't want to do hormone therapy. So looking at more estrogen plant-based supplements to the diet can be an option. The changes, however, aren't necessarily bad. They're just changes. And so on the other side of these changes, and of course any change in a period of change is going to be a fluctuating, you know, it's like, ah, I don't know what's going on. I don't know where to— once you land on the other side and your voice is stable again, which can take a couple of years, now you perhaps have a richer, fuller voice than you had before. And you've got more stories to tell with your voice. And so embracing the new changes to your voice. But can I share a real quick story with you from one of our singers. She just emailed 2 weeks ago. She said, "I just want to thank you for shining a light on the issue. I'm 54 years old." She's a singer, teacher, and music director who spent the last decade battling increasing vocal fatigue and loss of her high register. She saw 4 different ear, nose, and throat specialists, multiple speech pathologists, and had multiple strobes of her throat. And every time she was told there was nothing physically wrong. And that is exactly the case. It won't look like anything is wrong. And that's because it isn't necessarily wrong, it's just changing. She said— and so she said, after doing my own online research, I asked my OB-GYN for estrogen and it was refused since vocal fatigue is not on the symptom treatment list. So she sought out a doctor who would prescribe estrogen off-label for her vocal fatigue, and it improved her symptoms almost immediately. And she, she begged, the medical community needs to be educated, so thank you for being part of that.

We're talking to Nancy Bos. She is a vocologist and she's the co-author of the book Singing Through Change: Women's Voices in Midlife, Menopause, and Beyond. And she co-wrote the KevinMD article, Menopause Changes Women's Singing Voices. Nancy, I'm a primary care internal medicine physician. So what kind of symptoms should I be looking out for that may point to the direction of menopause-associated voice changes?

Some of the symptoms are directly addressed to the vocal folds themselves. For instance, a woman might— I don't know why she would tell this to the primary care physician, so the first thing I would say is perhaps you want to ask. If she says, "Oh, I'm in my choir, but it's not so much fun anymore," you might want to say, "Well, what's going on?" And if she says, "My breath capacity isn't the same," or "My voice glitches, I lose a few pitches," or "There's a blank spot in my voice," or "I just can't sing high like I used to," there's a number Another issue that we are just uncovering, which I call pitch insecurity, and it is a pitch perception issue. And the woman would say, "I was told that I was singing flat, but I knew I wasn't flat." Well, she probably was because we're uncovering this new perception of our pitch being wrong for brief periods during perimenopause. So any kind of complaint about the voice like that, it might also point to GERD, which is very common in perimenopause and menopause. And that, that dry mouth, that Sahara dry terrible mouth feeling that, that women in menopause get, that's also impacting their singing.

And my final question, what's your take-home message that you want to leave with the KevinMD audience?

Thank you. I have two. One is that, as you all know, we are always changing. So letting your patients, your women, know that change is normal, and let's help you walk through this and accept the change. But the other one, the one that is really important to me with this audience, is that singing voice changes are a menopausal symptom, and I would love to have them be acknowledged.

Nancy, thank you so much for sharing your time and insight, and thanks again for being on the show.

Thank you so much.