HORMONES AND THE FEMALE VOICE: AN EXPLORATION OF THE FEMALE HORMONAL CYCLE FROM PUBERTY TO MENOPAUSE AND HOW IT AFFECTS THE VOCAL APPARATUS A Dissertation Submitted to the Temple University Graduate Board In Partial Fulfillment of the Requirements for the Degree DOCTOR OF MUSICAL ARTS by Patricia Vigil July 2015 Examining Committee Members: Dr. Christine Anderson, Advisory Chair, Department of Voice and Opera Dr. Rollo Dilworth, Department of Music Education and Therapy Dr. Lawrence Indik, Department of Voice and Opera Dr. Joyce Lindorff, Department of Keyboard Studies © Copyright 2015 by Patricia Vigil All Rights Reserved ABSTRACT The purpose of this paper is to examine the female hormonal cycle throughout a woman’s life and its effects on the singing voice. Dealing with vocal issues brought on by hormonal fluctuations can be extremely frustrating for the professional singer, as these issues can wreak havoc on performance and practice schedules. The best weapon of defense against its unpredictability is information. Unfortunately, data on the female hormonal cycle and its effects on the voice is not covered in most standard vocal pedagogy books. Information on the subject is often relegated to a small section of a chapter, and even then usually describes only the symptoms: edema, hoarseness, and loss of high notes and power. The question as to why these symptoms happen every month and during menopause, and whether there is anything that can be done to alleviate them, remains largely unanswered. A candid discourse on the subject of hormones and the female voice has begun, but now must brought into the open. It is a subject that needs to be broached in voice studios everywhere. Can the effects of hormonal fluctuations on the voice be managed? What treatments are there for the symptoms; are they safe; are they effective? How can we further the dissemination of information on this subject? This paper will attempt to answer these questions by compiling data from the studies and research of esteemed doctors and scientists on this subject into one document, making it easy for young students and interested voice teachers to access this important information. It is my goal with this monograph to help and inform my readers. The human larynx is directly influenced by lifelong cyclical hormonal fluctuations. A woman’s monthly cycle, which lasts from puberty to menopause, causes ii changes in hormone concentrations. These changes can affect a woman’s physical and emotional states, causing bloating, and temporary abnormalities in sleep, mood, concentration levels, and energy. These effects are also seen in the vocal tract, where edema, vocal fatigue, decreased range, and lowering of the fundamental frequency can occur. The monthly symptoms of hormonal change are called premenstrual syndrome, or PMS. Similarly, the symptoms manifested in the larynx are called premenstrual vocal syndrome, or PMVS. This paper is an examination and exploration of the effects of PMS and PMVS on the singing voice. To do so, it provides a brief overview of the steroid hormones: estrogen, progestogen, and androgen. These three hormones are responsible for the development and maturation of primary and secondary sexual characteristics. It is only through studying the specific functions of each of the steroid hormones that it is made clear why some women suffer so profoundly each month from PMS and PMVS. Additionally, this paper provides information regarding the benefits and drawbacks of oral contraceptives, or OCPs. OCPs contain synthetic hormones that mimic the body’s own natural hormones, and they regulate the body’s levels of estrogen and progesterone, which prevents ovulation. In addition to their contraceptive use, OCPs are used to treat endometriosis, acne, and irregular periods. By preventing the body’s hormonal levels from fluctuating, OCPs have proven highly effective as a treatment of PMS and PMVS. Further, the changes to the voice during pregnancy will be examined. The increased hormonal concentrations associated with pregnancy act upon the reproductive organs, muscles, bone, cerebral cortex, and mucosa, as well as the larynx. This paper also explores what happens to the voice throughout the stages of menopause, the iii symptoms of which can range from moderate to quite severe. Treatment options are discussed, including both hormone replacement therapy and alternative methods. Lastly, this paper shares information gathered from a survey of singers regarding their own experiences with PMS and PMVS, OCPs, pregnancy, and menopause. iv ACKNOWLEDGMENTS To my advisor, Dr. Christine Anderson: Thank you so much for your encouragement and mentoring. Thank you for the opportunity to pursue my dream. To the members of my brilliant doctoral committee, Dr. Lawrence Indik and Dr. Rollo Dilworth: Thank you so much for insight, support and guidance. To Dr. Joyce Lindorff, external reader on my doctoral committee: Thank you for bringing a fresh and different perspective to the table, and for taking time from your busy schedule to help me in this endeavor. To the participants of the survey: Thank you so much for taking the time to share your experiences. Your input and comments are invaluable. There are no words to express my gratitude; thank you from the bottom of my heart. To Julia Madden Gerhard: Thank you so much for being my guardian angel and pointing me in the right direction. To Kristi Morgridge: Thank you for always having the answers to my questions. To David Arnold: Thank you for your knowledge, inspiration, and encouragement. To Dean Edward Flanagan: Thank you for all of your assistance. To Dean David Brown: Thank you for everything. To my wonderful husband, Daniel Lickteig: Thank you so much for all your love, patience, support, and assistance. None of this would have been possible without you. I love you. To my family and friends: Thank you for all your encouragement. v TABLE OF CONTENTS ABSTRACT ......................................................................................................................... i ACKNOWLEDGMENTS ................................................................................................. iv LIST OF FIGURES ........................................................................................................... vi CHAPTER 1. INTRODUCTION ......................................................................................................... 1 2. SEX HORMONES AND HOW THEY AFFECT THE FEMALE VOICE ................ 19 3. ORAL CONTRACEPTIVES AND THEIR EFFECTS ON THE VOICE .................. 39 4. THE IMPACT OF PREGNANCY ON THE VOICE ................................................. 60 5. THE EFFECTS OF MENOPAUSE AND THE VOICE ............................................. 68 6. HORMONES AND THE FEMALE VOICE SURVEY ............................................. 81 7. SUMMARY ................................................................................................................. 93 BIBLIOGRAPHY ............................................................................................................. 96 APPENDICES A. IMAGES OF THE LARYNX .................................................................................... 108 B. GLOSSARY ............................................................................................................... 111 C. THE SURVEY QUESTIONS .................................................................................... 113 D. PARTICIPANTS’ COMMENTS FROM THE SURVEY ........................................ 118 E. PROTOCOL SUBMITTED TO THE IRB ................................................................ 134 vi LIST OF FIGURES Figure 6.1: Percentage of Women Suffering from PMVS by Voice Type ....................... 83 Figure 6.2: The Effects of Pregnancy on Women’s Voices.............................................. 85 Figure 6.3: Vocal Issues Caused by Peri-Menopause or Menopause ............................... 87 Figure 6.4: Treatment of Menopause Symptoms .............................................................. 88 1 CHAPTER 1: INTRODUCTION Dealing with vocal issues brought on by hormonal fluctuations can be extremely frustrating for the professional singer. The female hormonal cycle and its fluctuations can wreak havoc on performance and practice schedules. Unfortunately, data on the female hormonal cycle and its effects on the voice is not yet covered in most standard vocal pedagogy books. Information on the subject is often relegated to a small section of a chapter, and even then usually describes only the symptoms: edema, hoarseness, and loss of high notes and power. The question as to why these symptoms happen every month and during menopause, and whether there is anything that can be done to alleviate them, remains largely unanswered. For instance, in his book The Structure of Singing, Richard Miller devotes a paragraph in a subsection of a chapter to the effects of oral contraceptives, and two sentences to pregnancy. Miller questions whether pregnancy is the right option for a career-minded singer, and he merely advises singers to consult with their laryngologist before deciding on oral contraceptives. In his later book, Solutions for Singers: Tools for Performers and Teachers, Miller states that hormonal changes may compromise the longevity of a female’s singing career. He goes on further to suggest that the voice categories which mature first, coloraturas and soubrettes, may be the first to experience vocal decline. Miller advises against giving