The aging female voice: Medical treatments and pedagogical techniques for combatting the effects of aging with emphasis on menopause
TABLE OF CONTENTS
I. The Aging Process and Its Effects on the Voice 1
II. Menopause: Medical Treatments and Pedagogical Techniques 30
III. Survey of Menopausal Singers 44
IV. Conclusions 71
APPENDIX A 79
APPENDIX B 80
RECITAL PROGRAMS 84
1. Larynx evolution since millennia 10
2. Follicular phase and Luteal phase: smear tests 11
3. Healthy vocal folds in the middle of the menstrual cycle
4. Vocal folds at Day 25 of menstrual cycle 13
5. Smear tests at menopause 14
6. Cellular glands above and under the free edge of the vocal fold 15
7. Atrophy of the right vocal fold
8. Boulet/Odden Study-Background characteristics of respondents 18
9. Respondent’s perceptions as to whether the voice changes at age 50 18
10. Results from Boulet/Odden Study. Types of voice change 18
11. Finding Of Women’s Health Initiative 31
12. David Jones’s list of Menopause Symptoms 39
13. David Jones’s critical vocalizes for menopausal/postmenopausal singers 43
14. Siarris Survey, graph for question 1 45
15. Siarris Survey, graph for question 2 46
16. Siarris Survey, graph for question 3 47
17. Siarris Survey, graph for question 4 48
18. Siarris Survey, graph for question 5 49
19. Siarris Survey, graph for question 6 50
20. Siarris Survey, graph for question 7 51
21. Siarris Survey, graph for question 8 52
22. Siarris Survey, graph for question 9 53
23. Siarris Survey, graph for question 10 54
24. Siarris Survey, graph for question 11 55
25. Siarris Survey, graph for question 12 56
26. Siarris Survey, graph for question 13 57
27. Siarris Survey, graph for question 14 58
28. Siarris Survey, graph for question 15 59
29. Siarris Survey, graph for question 16 60
30. Siarris Survey, graph for question 17 61
31. Siarris Survey, graph for question 18 62
32. Siarris Survey, graph for question 20 63
THE AGING PROCESS AND ITS EFFECTS ON THE VOICE
Medical advancements, plastic surgery, liposuction, Botox, the spa, the gym, Yoga, Pilates, and all that promotes our looking and feeling younger demonstrate society’s captivation with youth. If forty is the new twenty, then fifty must be the new thirty. Thus, the quest to stay young preoccupies those who are aging. Many physical changes occur in the body during the aging process. Singers and their voice teachers should know and be prepared for how these changes will affect their instruments. Aging, for instance, produces alterations within the vocal apparatus, including the laryngeal skeleton, vocal folds, and position of the larynx. It also produces changes related to vision and hearing as well as changes in the respiration and cardiovascular systems. These changes have an impact on singing. Hormonal fluctuations that occur during menopause can be an especially challenging issue for women between the ages of forty and fifty-five who may be at the height of their singing career. Although technically not a medical condition, menopause affects the voice through estrogen deprivation. Vocal changes that may occur include hoarseness, breathiness and a reduction in range, particularly in the top voice. In addition, swelling of the vocal folds and changes in the amount and consistency of the
mucous that lines the vocal tract are caused by a decrease in estrogen level. 1
Some women choose to give up singing during this time, yet singers and their teachers should be aware that prolonging the quality singing years is possible. Although it is impossible to reverse the aging process, it is important to know that some symptoms may be postponed or corrected. Just as physical exercise improves the cardiovascular and respiratory systems, researchers have found that regular vocal exercises minimize the consequences of the aging voice. 2 Commonsense practices such as proper nutrition, weight control, and the avoidance of smoking not only aid the quest to remain youthful but also aid vocal longevity. “Respiratory function normally decreases with advancing age. In particular, residual lung volume increases, with a consequent decrease in vital capacity, tending to undermine the primary respiratory improvement resulting from earlier voice training.” 3
Since the older adult loses elasticity and abdominal muscle mass, it is important that aging singers remain in top physical condition. If the singer has trouble walking up a few flights of stairs without becoming winded, it will be difficult to maintain the abdominal support and stamina needed to sing a recital, opera, or choral performance. Abdominal support is the power source of the voice. When it is undermined due to aging, the body compensates by resorting to excessive use of neck and tongue muscles. This leads to tension in the body which will affect sound quality. Keeping fit and conditioning the
1 Abby Butler, Vicki A. Lind, and Kimberly Van Weelden, “On the Voice: Working With the Senior Adult Choir,” Choral Journal 43, no. 5 (December 1976): 31.
2 Robert Peppard, “Effects of Aging on Selected Vocal Characteristics of Female Singers and Non-Singers” (Ph.D. diss., University of Wisconsin, Madison, 1990).
3 Robert Thayer Sataloff, “LaryngoSCOPE: Vocal Aging and Its Medical Implication: What Singers Should Know-PART II.” Journal of Singing-The Official Journal of the National Association of Teachers of Singing 57, no. 2 (November-December 2000): 57.
abdominal muscles restore good support of the voice. Regular vocal exercises will eliminate some of the problems related to age. Attention to these physical and vocal exercises may eliminate the dreaded tremolo, while improving agility, accuracy and endurance in the older singer. Levels of estrogen and progesterone change throughout the menstrual cycle. As these levels rise and fall, the effects are seen on the larynx. 4 With the onset of the premenstrual period, the amount of estrogen and progesterone are at their lowest during the menstrual cycle. Changes of the voice reported during this time include vocal fatigue, decreased range, loss of power, and changes in vocal color. Menopausal women report similar symptoms. Estrogen declines at menopause, resulting in loss of muscle mass throughout the body. Bone density is also lost giving small-bodied women predisposition to osteoporosis and bone fractures. 5
Because of the reduction of estrogen brought on by menopause, there are also changes in the larynx. Estrogen’s primary function is to maintain the tone and bulk of skeletal muscles, including those of the larynx and vocal folds. Many women experience atrophy of the vocal fold muscles and reduction of the mucosa of the vocal folds. Symptoms reported include increased vocal fatigue, decreased vocal intensity, and loss of upper range and vocal agility. According to Dr. Yolanda D. Heman’s study, twenty to thirty percent of menopausal women report symptoms of menopause vocal syndrome and will benefit from hormone replacement therapy. 6
4 Yolanda D. Heman-Ackah, “Hormone Replacement Therapy: Implications of the Women’s Health Initiative for the Perimenopausal Singer,” Journal of Singing 60, no. 5 (May-June 2004): 471.
Chronological aging is inevitable. There are choices, however, when it comes to biological aging. In fact, biological aging is a process over which we have a considerable amount of control. Teachers should be aware of vocal issues specific to women. The menopausal student has unique issues related to her voice and responsible pedagogues should inform themselves of recent findings concerning these issues. Menopause does not have to be the end of singing. According to Dr. Ronald Brown, life expectancies over the years have increased with scientific discoveries. Whereas in 1800 people in the United States were expected to live to twenty-eight years, by 1900 the average life span had increased to forty eight. In the year 2000, it is approximately eighty years. In 1900, the two major causes of death were pneumonia and diarrhea. Due to rapid advances in basic medical care and hygiene during the twentieth century, public health improved dramatically. Thanks to sterile techniques, antibiotics, immunizations and other scientific advancements, the major causes of death are now cancers, cardiovascular disease, (heart attacks and strokes), and neurological diseases, (Alzheimer’s disease, Parkinson’s disease.) “These are the diseases of older people—of aging.” 7
Dr. Brown goes on to state that “people’s hormones don’t decline because they age, but people age because their hormones decline.” He reasons that maintaining hormones at youthful levels will slow the biological aging process. People live longer and more productive lives now. As women age, their hormone production drops quite abruptly over the span of a few years. Menopause occurs, and menstrual periods and the hormonal fluctuation that created the cycle cease. With this decrease in production of
7 Ronald L. Brown, M.D.; The Youth Effect A Hormone Therapy Revolution (St. Augustine, Florida: Fine Books Publishing Company, 2007), 18.
hormones, the signs of aging begin to show. With every year that passes after reproductive life is over, the human becomes more vulnerable to disease and death. With their unhealthy diets, lack of exercise, toxins in the environment, and constant stress over a lifetime, conditions give way to an unnatural demise. 8
Anecdotes from Aging Divas Writer Tamara Bernstein discusses a performance of “O don fatale” from Verdi’s Don Carlos at the Salzburg Festival sung by the incomparable Christa Ludwig. As Miss Ludwig reaches the climatic high notes in her aria, her voice cracks. This is only one note out of thousands in the performance, one note out of millions in her career. This is only one note, one less than beautiful note. Yet, this devastating note causes this grand Diva to slink out of town, not finishing the run of the show, never to sing the role again. The newspaper announces “A star has fallen from the heavens.” Critics had long hailed her for her full, ripe, voluptuous voice, calling her “powerful humanity.” She must leave town in disgrace. Miss Ludwig describes this experience as “one of the great taboos of the singing world: Menopause.” 9
Classic menopausal symptoms include hot flashes, memory loss, vanishing libido, vaginal atrophy, fatigue, insomnia, mood swings, and anxiety. These hormonal changes can begin before menopause, when the ovaries reduce production of estrogen and progesterone. The body’s production of androgens, the male hormone, stays at the same level, causing a thickening of the vocal folds and a drop in vocal range. A similar event
9 Tamara Bernstein, “Is the Opera House Hot Or Is It Just Me? Menopause, Which Can Mean Disaster For A Diva At Her Peak, Is Opera’s Last Taboo,” The National Post (May 10, 1999): 1.
occurs to a boy’s voice during puberty. This reduction of female hormones causes swelling or dehydration of the vocal folds and affects the vocal mechanism. Each woman is different in her reaction to menopause. Some women never have a single hot flash. Others are extremely sensitive to even a minute change of estrogen levels. Heavier women encounter fewer problems during menopause. According to world-renowned French otolaryngologist and laser surgeon Jean Abitbol, fat cells store estrogen and convert male hormones to estrogen. Women who are carrying extra weight have an easier time with symptoms of menopause and require less hormone replacement therapy (HRT) than thinner women. Hormone replacement therapy involves one or more groups of medicines and is designed to artificially boost hormone levels in menopausal women suffering the discomfort caused by diminished estrogen and progesterone. 10
Christa Ludwig did sing for many years after the infamous Don Carlos and retired in her late sixties. She had a difficult time singing through menopause and recounts it as “a hell of some years,” adding that at times her vocal cords felt as if they were made of glass. She felt that they were so fragile that she was afraid to sing a pitch at fortissimo. Ludwig feared daily that her voice would not be there. In her early forties, she went to doctors complaining of vocal problems and was told that she was singing and talking too much. She believes that she was in early menopause brought on by turmoil in her life as she was going through a divorce. She tried numerous hormone related medications and had no luck for longer than six weeks at a time. Finally, she was prescribed a drug called
10 Ibid., 2.
ovestin, an estradiol hormone that her doctors thought would make no difference. This drug worked for her. 11
William Riley, a leading New York City voice coach, whose clientele include many famous operatic sopranos, says that menopausal singers fear that they will lose their top notes. Riley states that sometimes the quality of the voice changes and the range stays the same. Sometimes both change significantly. With some singers there is an improved quality in the voice. According to Riley, a menopausal singer’s hearing can sometimes change which may upset the singing mechanism. Memory loss is another fear of aging sopranos. 12
Society as a whole values beauty, youth, and femininity—so too in the opera world. Sex symbols like Carmen or Aida’s passionate rival Amneris tend to be the “juiciest roles.” The opera world is unforgiving and the aging soprano must have a thick skin when less than perfect pitches creep in. There are stories of famous sopranos, still singing past their prime, receiving bouquets of dried up roses to commemorate a less than perfect performance. 13
Evelyn Lear tells young singers “if you’re going to survive in this profession, you need to have the hide of an elephant and the soul of a butterfly.” Miss Lear summarizes her experience with menopause by saying, “You’re not singing on your interest anymore. You’re signing on your capital. And that can be dangerous.” Lear was in her mid-forties when menopause started. She had a major vocal crisis and withdrew from the stage. She found a new voice teacher and began to rebuild her technique. In 1970, at age forty-
11 Ibid., 3.
eight, she made a triumphant come back and enjoyed a prosperous career until age sixty. When she was asked about HRT, she stated that she never went to doctors. 14
Significant Research Jean Abitbol began his research with singers and hormones during the early 1980s. Many coloratura sopranos came to him complaining that they could not sing high notes for several days before their menstrual periods. Abitbol says that he sees menopausal singers who complain of losing their upper voice. They note less supple and sensual sounding voices and have difficulty singing softly. These singers also complain that their vibratos begin to wobble. The majority of the sopranos that he sees fear loss of femininity in their voices. Jean’s wife, gynecologist Beatrice Abitol, gave her husband a remedial course in pre-menstrual syndrome. The couple then began a “ground breaking study on the effects of the menstrual cycle on the voice.” Abitbol would take a smear test of a singer’s vocal folds at different stages of the menstrual cycle. He would then send the singer down the hall to his wife who would do a cervical smear. “When we put the two sets of slides together, we could not tell whether it was the vocal fold or the cervix, he said. In other words, the cellular changes in the vocal folds over the course of the menstrual cycle mirrored those of the cervix.” This proved that the larynx is indeed a target organ for hormonal changes. Ludwig stated: “The vocal chords are much like the vagina, it is the same issue. When one is dry, the other is also.” 15
15 Ibid. ,4.
In the well-known and widely quoted article “Sex Hormones and the Female Voice,” the doctors Abitbol studied a group of 197 women who were either premenstrual or menopausal. These authors examined the relationship between the hormonal climate and the female voice through discussion of hormonal biochemistry and physiology. The Abitbols explain that the female voice evolves from childhood to menopause “under varied influences of estrogens, progesterone, and testosterone.” These hormones determine and dominate voice changes throughout life. A female voice will develop masculine characteristics after an injection of testosterone. These changes are irreversible, just as the male castrati had feminine voice characteristics due to the lack of physiological change associated with testosterone. In their study of menopausal women, all showed signs of vocal muscle atrophy, reduction in the thickness of the mucosa and reduced mobility in the cricoarytenoid joint. HRT and multivitamins were prescribed. 16
The female voice and hormones—two words that seem to bear no relation to one another in our conventional wisdom—may meet and harmonize in the female body. One is intangible, emotive, symphonic, a mirror of its owner; the other is chemical, a molecular formula, rational, and entirely scientific. What is the link between them? Does voice have gender? Is the vocal gender identity determined at the chromosomal or hormonal level? 17
In this article’s introduction, the authors Abitbol et al. describe the human voice as a combination of stringed instrument (pitch determined by tone), wind instrument (air between vocal folds causing vibration and sound), and percussion instrument (rhythm emitted by mouth, tongue, and cheeks). The article also gives a brief history of the
16 Jean Abitbol, Patrick Abitbol, and Beatrice Abitbol, “Sex Hormones and the Female Voice,” Journal of Voice Vol.13, No. 3 (September 1999): 425.
development of the larynx, from prehistoric man to the Greek civilization, and describes the “bipedal, erect stance of homo sapiens which allowed the brain to develop and the larynx to drop from the first to the fifth cervical vertebra, allowing for speech (See fig. 1.) 18
Fig. 1. Larynx evolution over millennia. From Abitol et al, “Sex hormones and the female voice,”: 425.
The authors ask two questions in particular: How does the voice of a woman in her years of sexual activity vary? Does a premenstrual vocal syndrome exist? Clinical symptoms found in singers included vocal fatigue, decreased range, loss of high notes, and difficulty singing pianissimo. Although low tones were rarely affected, subjects noted a loss of vocal power and certain high harmonics, along with a more metallic, huskier sound. A series of vocal fold and cervical smears were taken by the Abitbols.
18 Ibid., 426.
These smears were performed on the same day. “Correlation was extraordinary and perfectly concordant with all the patients’ ovulation and on days 25-27 of the cycle”(See fig. 2.) 19
Fig. 2. Above left, Follicular phase: 20 Smear-test of the vocal fold; above right, Follicular phase: Smear-test of the cervix; below left, Luteal phase: 21 Smear-test of the vocal fold; below right, Luteal phase: Smear-test of the cervix. From Abitol et al, “Sex hormones and the female voice,”: 436.
19 Ibid., 435.
20 The follicular phase of the menstrual cycle is the phase in which the follicles in the ovary mature. This phase ends with ovulation. The main hormone controlling this stage is estradiol.
21 The luteal phase of the menstrual cycle is the latter phase. The main hormone associated with this phase is progesterone.
Fig. 3. Healthy vocal folds in the middle of the menstrual cycle. From Abitol et al, “Sex hormones and the female voice,”: 428.
Fig. 4. Vocal folds at Day 25 of the mensrual cycle. From Abitol et al, “Sex hormones and the female voice,”: 436.
Of the 97 premenstrual patients, 3 noted “hyper secretion of mucus on the folds” causing frequent throat clearing for three to four days of their menstrual cycle (See fig. 4.) All of the patients in the study showed signs of edema of the folds, with thickening mucus and loss of suppleness, resulting in disturbed muscular and vibration function. 22
The Abitbols’ second study group included 100 menopausal women, using no HRT. The appearance of their vocal cords was similar to the first study group who were tested on days 25-27 of their menstrual cycle. Seventeen percent of the women studied in the second group exhibited the vocal syndrome of menopause. These symptoms included lowering of vocal intensity, vocal fatigue, decreased range, and loss of resonance in the speaking and singing voice. This vocal syndrome was reported to be progressive and especially noticeable by voice professionals, including popular singers,
opera singers, actresses, lawyers, hostesses, school teachers, and others. Slow vocal deterioration was first noticed in high notes and pianissimos. These menopausal women were examined according to the same vocal exploration criteria as the premenstrual women with particular interest given to the cervical and vocal smears. As seen in figure 5, both the vocal smear and cervical smear “show mucosal sub atrophy with basophiles and a significant reduction of glandular cells.” 23
Fig. 5. Smear tests at Menopause. From Abitol et al, “Sex hormones and the female voice,”: 440.
23 Ibid., 439.
Figures 6 and 7 show vocal folds during menopause. In figure 7, the right fold shows significant atrophy. The mucosa has also lost its pearly white appearance 24
Fig. 6. Cellular glands above and under the free edge of the vocal fold. From Abitol et al, “Sex hormones and the female voice,”: 441.
Fig. 7. Atrophy of the right vocal fold. From Abitol et al, “Sex hormones and the female voice,”: 441.
24 Ibid., 440.
In “Female Voice Changes Around and After Menopause-An Initial Investigation,” Monique J. Boulet and Björn J. Oddens studied 48 females and 24 males who were professional singers aged 40-74 years old to determine whether women and men’s voices age in different ways. Is menopause a factor in vocal change? Seventy- seven percent of the women interviewed and seventy one percent of the men were of the opinion that the voice underwent changes around the age of 50. Female singers reported negative changes in the upper registers and problems with voice control more often than men. Twenty-nine percent of women experienced negative voice changes around age 50, compared to thirty eight percent of men. Men and women reported huskiness; however, women frequently had more problems with voice emission, voice control and reaching their highest registers. Twenty-seven of the women reported voice changes during menstruation and 5 women reported voice change during the use of oral contraceptive pills. The broad findings from this study indicate that female singers experience voice change during menopause. 25
Because the voice is produced within an inner environment and depends on simultaneous function of mucous membranes, muscles and cartilage, the authors of this article wondered what changes occurred in the voice during the time of menopause. During their investigation, they discovered that female opera singers tended to retire between 55 and 60, while their male counterparts retired at 60 or over. A decline in ovarian hormones and the relative excess of adrenal androgens is thought to be the cause of these changes during menopause. These authors chose to target professional female
25 Monique J. Boulet and Björn J. Oddens, “Female Voice Changes Around And After Menopause-An Initial Investigation,” Maturitas 23 (September 1996): 15.
singers who they thought would be much more aware of voice quality, range, voice production and so forth. Male classical singers were also studied as a control group. 26
In Boulet and Oddens’s study, questionnaires were distributed in Belgium, the Netherlands, and Austria by teachers of professional singers and two Ear, Nose, and Throat doctors (ENTs) who specialized in singing problems. For females in the study, the questions concerned positive and negative voice changes, observed over twelve months prior to the study. Candidates were asked to give an extensive description of these changes, to describe the nature of these changes, and to state their ages. The singers were asked whether the changes occurred close to age 50 and whether they thought menopause caused these changes. They were also asked whether using the contraceptive pill or menstruation had effects on their voices. Questions concerning background, characteristics, country of origin; and professional activity were also included (See fig. 8.) 27 The males in the group were given identical questions. The final sample of questionnaires returned comprised 48 females and 24 males. The results from this study indicate that men and women thought the singing voice generally underwent changes around age 50 (See fig. 9.) Sixty-five percent of the women felt that these changes were due to menopause. Women reported huskiness, loss of ability to reach high notes, reduced suppleness of the vocal chords and impaired steadiness of the voice. Both sexes reported a change in vocal timbre (See fig. 10.) 28
27 Ibid., 17.
Age Women Men 40-47 years 14 7 48-55 years 12 8 56-63 years 17 7 64-74 years 5 2
Belgium 17 4 Netherlands 23 12 Austria 4 5 United States 2 2 France 1 0 Spain 1 0 Italy 0 1
Solo performer 34 13 Operatic choral singer 13 10 Other 1 1
Fig. 8. Background characteristics of respondents from Boulet/Oddens study (n = 72)
Voice generally changes 77% (37) 71% (17) Voice does not change 15% (7) 17% (4) Do not know / no opinion 8% (4) 13% (3)
Fig. 9. Respondent’s perceptions as to whether the voice generally changes at around age 50. Women Men Husky 25% (9) 6% (1) Loss of top notes 69% (25) 47% (8) Change in timbre 44% (16) 47% (8) Less supple vocal cords 72% (26) 47% (8) Voice less steady 36% (13) 24% (4)
N 36 17
Fig. 10. Results from Boulet/Odden study. Types of voice changes associated with fifth decade of life- only those respondents who considered that the voice generally changes at around age 50. From Boulet et al, “Female Voice Changes Around And After Menopause-An Initial Investigation,”: 17.
Berit Schneider, MD, speech pathologist at University of Vienna in Austria, observes that older sopranos are having vocal problems. During menopause, they were unable to reach high notes and lost range, as well as suffered from “raspy voices.” Their voices deepened and lowered in pitch. Schneider’s study group consisted of 107 women between the ages of 37 and 71, all postmenopausal. They were all asked about vocal changes and discomfort as well as their singing and speaking voices. Of this group, 46% mentioned vocal changes, with one-third of them complaining of vocal discomfort. Fifty- four percent reported no changes in their voices and no vocal discomfort. Of the 46% who noted changes, symptoms included “throat dryness, frequent throat clearing, lower voice frequency level, increased roughness and hoarseness.” 29
Ten of the forty-nine women were taking hormone replacement therapy (HRT). These ten women had thick mucus on their vocal folds, evidence of hormonal imbalance. Since hot flashes, heart palpitations, and vaginal dryness often take precedence over vocal concerns, these problems are seldom discussed in doctor’s visits. Complaints of vocal problems increased in the number of women ages 40-60. Schneider writes that various body tissues rely on the presence of estrogen to stay healthy. These women also suffered from the dryness and thinning of body tissues because of loss of collagen and muscle mass which likely affected the vocal chords. Smoking, Schneider adds, intensifies the problem, since it deactivates estrogen and causes earlier menopause. 30
29 Charlotte E. Grayson Mathis, M.D., review of “Voice therapy, Other Options Exist for Women Whose Voice Is Deepening,” by Jeanie Lerche Davis. http://www.webmd.com/menopause/news/20040316/voice-change-is-overlooked-menopause-symptom