One Singer’s Experience with Perimenopause

This is my story. I share it because the subject needs to be out in the open, and because if I had been more informed a few years ago, my confusion and vocal discouragement might have been minimized.

Just as every woman experiences her own version of reproductive menopause, every female singer eventually encounters her own unique “vocal menopause.” Many people in the world of singing are unaware that the larynx is a target organ of the female hormones estrogen and progesterone as well as male hormones, which women also produce though in small quantities. Articles I have read in voice journals and books on voice health confirm that essentially all of the symptoms I discuss below are the result of physical changes caused by the fluctuation and eventual decrease in estrogen and progesterone levels, and from the physical aging of the body. Though many female singers experience little or no vocal change during this time, apparently some 20-30 percent of women report menopausal voice symptoms(1), and still more show physical and acoustic changes, though they may be unperceived (2). Singers need to know that a drop in estrogen production can begin a number of years before the cessation of menstrual periods (which is actually the last sign of reproductive menopause).(3)

In retrospect, I believe that as early as age 45, I began to experience subtle vocal changes—and by the time I was 47, the effects were marked. (I was still having fairly regular periods and only a few of the typical physical signs of approaching menopause.) It is important to note here that as my voice changed, I unconsciously began to develop compensatory behaviors, notably jaw and tongue tension, in an attempt to “help” my voice work in its customary way. Poor technical adaptations like these can complicate and compound the voice changes in women who experience what Dr. Jean Abitbol—arguably the world’s leading expert on sex hormones and the voice2 —has coined the “menopausal vocal syndrome.”

Journals and books include a number of informative articles on the subject of menopause and its effect on the singing voice—but the ones that I have found are written by laryngologists, speech pathologists, voice researchers, and in two cases, gynecologists. Perhaps the following descriptions of certain symptoms I experienced, from my perspective as a singer, will be more detailed and subjective than the clinical accounts in the journals.

I remember that my voice felt more or less “normal” to me at a performance in June when I was 47 (though in retrospect, my husband noted a difference in vocal quality). By September, I was feeling definite and bewildering changes. In performances the following February and March—including a very uncomfortable Mozart Requiem, a part that had been an old, reliable friend—I knew something was fundamentally different with my voice. My symptoms included:

Masculinization of the voice: a tendency for the overall range to lower because naturally produced androgens (testosterone) become increasingly unopposed as estrogen levels diminish. I noticed this, though I’ve always had a low extension for a soprano, so this symptom wasn’t exactly dramatic. Loss of upper range is a related phenomenon.

Loss of “ring” in the tone. At the June performance mentioned above, my husband remembers that my sound didn’t have its typical “presence.” Acoustically, the perimenopausal and menopausal voice loses some upper partials, which are responsible for the characteristic brilliance, color, and carrying power of the classically trained singing voice. I speculate that unconsciously, I began to replace those missing high overtones by producing a brightness that was rooted in tension. It felt “ringing” to me, but was a counterfeit of the true acoustic phenomenon.

A slowing of quick responsiveness and flexibility. Rapid onsets and staccati became difficult, either on the same pitch, or in an arpeggio or scale. The coordination of pitch intent with clean closure of the folds and precise airflow was very awkward and sluggish.

A feeling of “thickening.” One teacher-singer I talked with used the word “woodening,” which I found apt. It was as if someone had performed a secret laryngeal transplant. My voice seemed foreign to me! I experienced a loss of suppleness and flexibility, and I don’t mean merely the ability to do coloratura easily and fluidly; I had lost that feeling of vocal “stretchiness.” Because I teach college-age singers, the contrast between their young, elastic voices and my “stiff” voice was readily apparent to me.

Difficulty with performing the diminuendo. The “slendering down” to piano became awkward. Rather than a gradual taper, the dynamic would reach a certain level, do an unwilled subito piano and then begin to go flat.

Instability of the middle range. For me, that area was A4 up to D5 or so and the instability affected how I entered the upper range. This was particularly bewildering because my middle voice had been one of my strengths as a singer. At one point, I e-mailed a friend who is a noted voice teacher. She replied that in her experience, this area of the voice can be a point of weakness during the change of life. When her message asked if I was having trouble at around B4 to Bb4, I burst into tears. Yes, I certainly was. Decreased coordination between the head voice and chest voice mechanisms, a symptom cited in one study of perimenopausal/menopausal singers, may be the issue.

Dryness of the mucous membranes of the throat and larynx, in spite of good hydration. I found this to be very annoying. Even walking at a reasonably fast pace would bring on a great dryness in my throat. Physical changes from lowered hormone levels and the natural aging process seem to be responsible.

A tendency to sing flat. I had difficulty sustaining a pitch in good tune, particularly in the middle upper voice. This was terribly distressing, as I had never experienced pitch problems before, and for obvious reasons, it caused me to shy away from performing. When I eventually saw an extremely well-regarded ENT who specializes in the care of singers, he remarked that my symptoms—and he cited this particular one—were probably “neuromuscular responses to lowering levels of estrogen.” His comment brought me some ease of mind, because it meant I had not become a terrifically bad singer after all. The root cause of these changes was beyond my control.

I should mention several other symptoms associated with menopause that are discussed in the journals: decreased vocal intensity, vocal fatigue, loss of vocal quality, cracking, difficulty in supporting, breathiness or weakness, change in vibrato, and the development of tremolo4. It seems to me that these symptoms should be as familiar to female singers and teachers of both genders as the symptoms of voice changes from gastroesophageal reflux.

Interestingly, one factor in the reason decreasing estrogen levels affect every singer differently is the singer’s amount of body fat. Women of more generous proportions actually produce estrogen in fat cells, which helps makes up for the loss of estrogen production from the ovaries and other endocrine glands. Thin females may suffer more menopausal symptoms, vocal and otherwise, than their more curvaceous colleagues2.

If it occurs to those of you who suffer from premenstrual vocal problems that some of the symptoms of perimenopause/menopause are similar to those you experience, you are correct. Voice scientists suggest that the hormonal landscapes during these phases resemble each other, resulting in several of the same physiological changes in the vocal instrument3.

My recommendation to any female singer in her 40s, or even late 30s, who thinks she may be experiencing hormone-related voice changes such as those outlined above: Make an appointment with a voice-care specialist as soon as possible. If you live in a large metropolitan area, it should not be difficult to locate either a voice-care clinic, possibly in a medical school, or an ear, nose and throat doctor (otolaryngologist) who has expertise in treating professional singers. Ask other singers and trusted voice teachers for advice regarding an appropriate voice specialist. If you live in a smaller or more isolated community, I would strongly suggest traveling to such a clinic or specialist, rather than seeing a local ENT, because not all doctors are aware of the very special needs of the trained singer. A thorough voice exam can rule out or treat any other physical issues, and the voice specialist can help you sort out how you will adapt to vocal changes if they are related to perimenopausal/menopausal hormone changes.

Treatment may include work with a skilled voice teacher and/or speech and singing therapist to address any poor compensatory behaviors that might have crept into your technique. In past years, voice-care experts freely advised singers to begin hormone replacement therapy (HRT) to counteract the effects of menopausal changes. The results of the Women’s Health Initiative Study, however (which ended in 2002), indicate hormone replacement should be considered only with great care1.

Consultation with a gynecologist and/or endocrine specialist will help female singers determine if hormone replacement is an appropriate choice. If HRT isn’t an option, singers may choose to pursue other treatment regimens that may benefit their voices without the attendant health risks of pharmaceutical hormones.

My story, which began with great emotional distress due to my bewildering voice changes, has become a much happier one. After my voice specialist said he suspected that falling hormone levels were the underlying cause of my voice troubles, he suggested that I go on a trial of HRT, after consulting with my physician. After seriously considering the risks versus the benefits, and looking at my family medical history, I decided I would give bioidentical hormone replacement a try.

I have experienced considerable improvement in vocal quality and flexibility, though it took working with my gynecologist in consultation with my ENT to find the most effective dosages over a period of time5. I continue to work with a teacher I trust to keep an eye out for those compensatory tensions and to reinforce good vocal technique, which has contributed to marked vocal improvement and comfort. Though circumstances don’t allow me to perform aggressively at this time, just being able to practice daily with ease and teach productively is highly satisfying. Granted, I haven’t recovered the physical voice of a 30-year-old—alas!—yet I feel I understand my voice all the better for having worked through the situation, and my teaching skills have certainly been enhanced.

If the story I tell, and the sensations and symptoms I describe, are familiar, I urge you to seek excellent medical and vocal advice. Don’t wait. You will likely prolong your vocal life and health, and recover freedom and pleasure in singing.

<b<Endnotes and sources:
1Y. Heman-Ackah, “Hormone Replacement Therapy: Implications of the Women’s Health Initiative for the Perimenopausal Singer,” Journal of Singing, 60 (2004): 471-475.

2J. Abitbol, P. Abitbol, and B. Abitbol, “Sex Hormones and the Female Voice,” Journal of Voice 13 (1999): 424-446.
3R. Sataloff, K. Emerich, and C. Hoover, “The Effects of Menopause on the Singing Voice,” Journal of Singing, March/April (1996): 39-42.

4R. Sataloff, K. Emerich, and C. Hoover, “Endocrine Dysfunction.” In: Vocal Health and Pedagogy, (San Diego: Singular Press; 1998): 167-173.

5My gynecologist says the “patch” version of estrogen delivery (such as Climera) may not be as effective in counteracting certain menopausal vocal symptoms. Simply stated, oral estrogen opposes the body’s production of testosterone, whereas estrogen from the patch does not. For more information, please discuss your specific situation with a gynecologist or endocrinologist.

“Though this middle-aged classical singer feels that the message about menopausal vocal syndrome deserves discussion in the public forum, she prefers to keep her privacy. She is a college voice teacher and has specialized in recital, chamber music and oratorio during her nearly 30-year career. She is married and the mother of three young adults.”