Menopause can disrupt women’s vocal tone and quality, says USF Health vocal researcher

A new USF Health study published Sept. 9 in the journal Menopause provides a comprehensive and innovative examination of a previously underexplored phenomenon: vocal changes that women may experience during menopause, often the result of falling levels of estrogen and progesterone.

The groundbreaking paper from a group led by Yael Bensoussan, MD, MSc, inaugural director of the USF Health Voice Center in the USF Health Morsani College of Medicine, and Rupal Patel, PhD, professor at Northeastern University, explains that those most likely to suffer unwanted voice changes - resulting in roughness, hoarseness and a loss of vocal stability - are women who use their voices professionally, such as teachers, actors and especially singers.

Voice production is a complex physiological process requiring "the precise coordination of multiple systems: respiration, phonation, articulation and resonance," said Dr. Bensoussan and her collaborators.

They explain that even small disruptions to any one of those elements can have an adverse impact on vocal function. Vocal folds within the larynx rely on musculature, mucosal pliability and proper airflow from the lungs to create sound. And the specific balance of tension and elasticity of the vocal cords play a key role in vocal quality.

Furthermore, the paper finds, "hormonal fluctuations play a critical role in maintaining the structural integrity of laryngeal tissues."

The paper details a wide range of options for treatment. Among them:

• Voice therapy: Overseen by a trained therapist, with the goal of a patient learning to vocalize with less effort.

• Steaming and hydration: This treats dryness of mucosal tissues through daily hydration with small amounts of water during the day, or inhaling steamed water.

• Systematic Hormone Therapy (HT): This is conducted in collaboration with the laryngology team and the patient's gynecology team.

• Bilateral vocal fold injection augmentation: This procedure is performed with injections into the vocal cords - either with local or general anesthesia - with the goal of "plumping up" the vocal cord folds to counter potential atrophy and ideally leading to an increase of volume and clarity.

In addition, AI-powered voice biomarkers provide a promising, noninvasive tool that can detect small changes in vocal function, including changes connected to the hormonal fluctuations caused by menopause.

"What needs to be done in the future is more research and more collaboration with gynecologists," Dr. Bensoussan said. "And hopefully there will be more awareness to refer patients with these symptoms to a voice specialist, rather than saying, 'Oh, it's normal, don't worry.' And we need more research to understand at what level does giving hormones help the voice - and who should we give them to?"

Dr. Bensoussan, also an assistant professor in Otolaryngology in the Morsani College of Medicine, is conducting research funded by a National Institutes of Health grant that has focused on creating a database of human voices of people with a variety of health disorders and conditions. Researchers are using artificial intelligence to analyze the data in order to determine whether differences in the voice may be biomarkers that reveal the presence of different diseases.

During her work seeing patients at the Voice Center, Dr. Bensoussan began to notice a curious trend.

"I was seeing a lot of middle-aged women just around menopause age, and they were coming in with very specific symptoms of rough voices, and dry coughs," she said. "When we looked at their vocal cords with the little camera, we didn't see anything abnormal. As a surgeon, I like to see something I can fix or remove. But these women just had tired voices, and that's when I got really interested in the potential affect of hormones and what those do to change the voice."

Dr. Bensoussan was intrigued that one of her patients, a singer, informed her that her vocal teacher could tell when she was having her period because her voice sounded different.

"Often these women - like many in women's health - are dismissed and told 'Oh, it's reflux, oh it's laryngitis, oh it's nothing,' and some women are relieved it's not serious like cancer so they're happy and go no further with it," she explained. "But a lot of these voice professionals are being dismissed because there's not enough understanding that hormones have a huge impact on the voice."

Dr. Bensoussan was drawn further into the issue due to the practice of treating menopausal women with hormonal therapy that involves testosterone, to counter balance the decrease in estrogen and progesterone.

"Unfortunately, testosterone is a male hormone and one of the side effects is a 'more masculine' voice," she said. "And these women are not counseled for that. So they get to my office and, I can tell within two seconds of speaking with them what's going on. I ask if they're on testosterone, and they say, 'Yes,' and it's really terrible for them. Many cry and say they were never told that it would affect their voice."

Around the same time, her Northeastern colleague Dr. Patel shared that she had noticed her own voice change and had also heard from peers and friends in perimenopause who were debilitated by voice, sleep and focus issues.

"She was like, 'This is crazy, but now I really understand the symptoms,' " said Dr. Bensoussan. "So I met her and got interested in learning more."

The idea to do a study crystalized when she received an email from a Dallas gynecologist, Cheryl Kinney, MD, who had heard about Dr. Bensoussan's voice research. Dr. Kinney also worked with many women, including singers, going through menopause and experiencing vocal problems. She invited Dr. Bensoussan to speak on the topic at a well-attended Menopause Society event in Chicago and the crowd was riveted. "I think it's because they were surprised," Dr. Bensoussan said. "They didn't understand or appreciate the effect of hormones on the voice."

That spurred Dr. Bensoussan to undertake the study, which also included Northeastern's Dr. Patel serving as senior author. Among their conclusions: AI-powered voice biomarkers provide a promising, noninvasive tool that can detect small changes in vocal function - including changes connected to the hormonal fluctuations caused by menopause.

"What needs to be done in the future is more research and more collaboration with gynecologists," Dr. Bensoussan said. "And hopefully there will be more awareness to refer patients with these symptoms to a voice specialist, rather than saying, 'Oh, it's normal, don't worry.' And we need more research to understand at what level does giving hormones help the voice - and who should we give them to?"