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Voice Changes: A Lesser Known Symptom of Menopause

As many as 77% of women report changes in their voice, typically described as deepening, raspiness, and/or fatigue, associated with menopause. For most women, the change is, at most, annoying, but for women who use their voice professionally, a subtle voice change can end their careers. Sex hormones (estrogen, progesterone, and testosterone) have a profound effect on voice, particularly during puberty and menopause. Testosterone causes the larynx to elongate and enlarge as well as the vocal cords to become thicker, producing a lower pitched sound in men. In the presence of higher levels of estrogen and progesterone and lower levels of testosterone in girls during puberty, the vocal cords become more thin than before puberty and stay short, producing a higher pitched sound.

As a reminder, the larynx (voice box) is a tubular structure that connects your throat to your trachea (windpipe) en route to your lungs. Inside the larynx are the vocal cords, which are rubber-band-like structures that stretch across it. Vibration caused by air passing across your vocal cords is how sound/voice is produced. Contracting and relaxing the muscles of the larynx produces different types of sound.

During menopause, lower estrogen in women means that the vocal cords receive a relative increase in exposure to testosterone and other androgens, which thickens the vocal cords, producing a deeper voice. Menopausal women also have a decrease in collagen, which, together with lower estrogen, results in dehydration of the vocal cords. Dehydration can lead to vocal fatigue, making it harder to hit high notes and to produce a clear tone. Voice professionals often report an increase in the length of time they need to rest between performances, and in studies of all types of menopausal women, there is a higher incidence of throat clearing, dryness, and hoarseness than in premenstrual women.

Lower estrogen also changes the mucous membranes that line the vocal cords, causing swelling and a decreased ability to hit high notes. Interestingly, there are also subtle voice change during the menstrual cycle of reproductive age women, with higher estrogen during the first two weeks of the cycle (follicular phase) producing thin mucus that permits better movement. The decreased estrogen during the second two weeks (luteal phase) of the menstrual cycle is correlated with thicker mucus and swelling. Vocal cord congestion (laryngitis) is at its worst at the end of the luteal phase, when progesterone levels are at their highest and estrogen is low. Female singers have a more difficult time reaching the highest notes during the last few days of the luteal phase, which is immediately before their period starts, and the first few days of their period. Menopausal women experience a much more significant change in pitch compared with their premenopausal voice.

Estrogen therapy has been shown to be particularly helpful in delaying unwanted voice changes and even returning the original voice to ~70% of menopausal female singers after one year. This finding is consistent with studies that have found that young women with primary ovarian insufficiency, which causes low levels of estrogen, experience the same voice changes as menopausal women. Other studies have concluded that the estrogen (estrone) made by fat tissue in obese women protects them from the voice changes. Despite the impact of low estrogen, it is not currently recommended that menopause hormone therapy (MHT) be prescribed solely for the treatment of voice changes due to a lack of well-controlled studies on large groups of women. However, if you have other menopause symptoms like hot flashes, night sweats, or vaginal atrophy, MHT likely will help delay/reverse your menopause-induced voice changes. Women who are voice professionals arguably should discuss the risks and benefits of MHT with their doctor, whether they have other menopausal symptoms for which MHT is recommended or not, since their livelihoods depend on their voice. In some studies, treatment with estrogen alone worked better for voice symptoms compared with estrogen plus progesterone. However, women with a uterus must take progesterone along with estrogen therapy to prevent uterine cancer, but estrogen therapy alone may be appropriate for women without a uterus. Voice therapy also has been shown to delay/restore a premenopause voice. In general, your OBGYN should work with an ENT to diagnose, treat, and evaluate your condition and the effectiveness of any treatment(s).

It's important to note that other things can cause voice changes - infections, diabetes, hearing loss, cancers, neurodegenerative disorders, and hypothyroidism/hyperthyroidism, among others - so it's important that you tell your doctor about any changes so that she can rule out other causes.

A growing research project called NIH Bridge2AI is attempting to build predictive models to assist in screening, diagnosis, and treatment of a broad range of diseases using changes in a person's voice. Previous studies have shown correlation between voice data and incidence of vocal pathologies (laryngeal cancers, vocal fold paralysis); neurological and neurodegenerative disorders (Alzheimer's, Parkinson's, stroke, and ALD); mood and psychiatric disorders (depression, schizophrenia, and bipolar disorder; respiratory disorders (pneumonia, COPD, heart failure, Covid-19, and sleep apnea); autism; and speech delay. In fact, some studies have shown an ability for AI to predict who will develop these conditions well before the development of other, more typical, symptoms. One hereto unaddressed question is whether voice can predict when a woman will enter menopause. That information might help women with family planning, career choices, and overall health. There are many negative health consequences linked to early menopause, including a higher risk of osteoporosis, cardiovascular disease, dementia, and early death. Interventions like preventative treatment and screening could be started sooner in an effort to ameliorate some of those early menopause risks. The myriad of seemingly unrelated symptoms that occur in perimenopause could be more quickly linked by medical professionals to menopause instead of an alternate explanation. Women considering gynecological procedures like hysterectomies to treat endometriosis might delay their procedure if they knew their menopause would start in one year versus five years since doctors know that endometriosis improves with menopause. Women might also use information about when they will enter menopause to make decisions about birth control. For example, when deciding whether to use an IUD that lasts for 7-8 years at age 45, it may be helpful to know if menopause was imminent so that another, less long-lasting option, could be chosen (although IUDs are sometimes prescribed to help women manage symptoms of perimenopause). Women considering the timing of childbirth might make different choices if they knew they had only two years, instead of eight, before menopause.

Voice changes are a less discussed symptom of menopause, despite most women experiencing it. Decreased estrogen in menopause permits an outsized effect of testosterone on the voice box that that lowers the pitch of voice. Further, low estrogen induces changes in the mucus and inflammation of the vocal cords and surrounding structures, as well as decreases collagen production and dehydration, resulting in pitch lowering, decreased ability to sing notes in the extreme ranges, hoarseness, raspiness, and vocal fatigue. Although medical organizations do not currently recommend MHT solely for the treatment of menopause voice changes, women with other menopause symptoms and/or those who use their voice professionally might benefit. Talk with you doctor about whether MHT or other treatments are right for you.

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