Voice changes, altered by hormone therapy, impact ‘at least one-third’ of menopausal women

Key takeaways:

• The changes associated with menopause and some hormone therapies can impact a woman’s voice.
• Gynecologists and laryngologists can partner to simultaneously improve women’s health and voice.

CHICAGO — Voice and respiratory changes can impact women’s health during menopause and hormone therapy plays a role in helping or worsening these changes, according to a speaker at the Annual Meeting of The Menopause Society.

Voice and speech contain important biomarkers that can give insight on women's health related to hormonal changes,” Yael Bensoussan, MD, MSC, assistant professor in the department of otolaryngology, head and neck surgery and director of the University of South Florida Health Voice Center, told Healio. “Women going through perimenopause and postmenopause can experience important voice and respiratory changes that can affect their quality of life and we have options to address them.”

According to Bensoussan, voice and respiratory changes are not usually brought up when talking about menopause and many patients are often misdiagnosed with reflux., That can mean women go without needed treatment as symptoms of dysphonia or “abnormal voices” impact their quality of life, mood and work efficiency.

How do hormonal changes impact voice?

Fundamental frequency, the pitch at which one speaks, starts at the same pitch as children and develops to be lower for men and higher for women during puberty, Bensoussan said during a presentation. With age, she noted, fundamental frequency lowers significantly with changing hormones and childbirth. As women age, structural changes, collagen loss and dryness in vocal cords can cause muscle atrophy and change the voice.

A study of 107 postmenopausal women, published in Menopause, found 46% had voice changes and 33% associated these voice changes with discomfort and impact on quality of life. In a study published in Clinical Linguistics & Phonetics, researchers also reported that respiratory function declines during menopause.

Yael Bensoussan

Hormone therapy (HT) also impacts the voice, according to Bensoussan. In a systematic review and meta-analysis published in JAMA Otolaryngology Health & Neck Surgery, researchers analyzed voice changes among menopausal women who were using and not using HT and reported that women using HT had closer to normal, less deep voices compared with women not using HT.

In Europe, some menopausal women are treated with intranasal estrogen for these vocal symptoms, Bensoussan said. In a study published in Journal of Voice, women using vs. not using HT had better voice quality and intranasal vs. systemic estrogen resulted in better voice quality. However, Bensoussan said, some HT such as testosterone and endogenous steroids can thicken vocal cords, lower vocal pitch and increase roughness.

Many voice changes caused by testosterone and endogenous steroid therapy are irreversible, Bensoussan said, and can occur early or later after HT use. One study reported a mean onset of voice change of 15 months. For these women, surgery or voice therapy can increase their pitch, according to Bensoussan.

A clinical trial, conducted by Huang and colleagues and published in the Journal of Clinical Endocrinology & Metabolism, evaluated blood work in women using testosterone therapy and the esearchers observed a dose-dependent effect on voice, with more testosterone concentrations resulting in worsening voice symptoms.

How to help

To improve the health of women with voice changes caused by menopause or impacted by HT, it is important clinicians advocate for voice change counseling when needed, know when to refer patients to a laryngologist, and conduct more studies to understand the impact of testosterone on voice and if any effects of testosterone are treatable, Bensoussan said.

Providers with voice clinics should also include hormonal histories, collaborate with women’s health experts and gain more familiarity with the potential effects of HT. In addition, Bensoussan said, in women’s health clinics it is important to include patient-reported outcomes when assessing vocal symptoms, collaborate with laryngologists, conduct voice change counseling and know when to refer patients.

The use of AI could be another strategy, according to Bensoussan. Voice could be ”one of the cheapest and lowest-resource” biomarkers and can be integrated with other digital biomarkers using sensors, which can benefit low-resource setting screenings.,

Bensoussan and colleagues are part of the Bridge2AI Voice project, launched by the Biden administration in 2019, which aims to build an ethically sourced, diverse and AI-ready database of 10,000 human voices linked to health information from mood disorders, respiratory diseases, voice disorders, neurological disorders and pediatric diseases. Currently, Bridge2AI Voice collects data on demographics, acoustic voice tasks, past medical history, confounders, validated questionnaires, clinician-validated diagnosis, digital literacy, disability status, languages, hearing tests, socioeconomic status and more.

“Voice and respiratory changes affect at least one-third of the women you treat and it’s important to talk about those and know when to refer [to laryngologists],” Bensoussan said. “Voice has a potential to become a biomarker of women’s health. We have to work together as voice experts, gynecologists and women’s health experts to try to make that work.”

According to Bensoussan, one goal of Bridge2AI Voice is to partner with women’s health clinics, collect longitudinal voice data, advocate for women’s health to benefit from voice biomarkers technology and develop new tools, such as voice trackers for menopause symptoms or for fertility.

“We need more research to understand the changes in voice linked to hormonal levels,” Bensoussan said. “Current research involves small cohorts of patients and lacks the ‘ground truth’ of serum monitoring. If we want voice to become a significant biomarker for women's health, we need bigger studies linking voice to hormonal changes.”

References:

• Awan SN, et al. Clin Linguist Phon. 2006;doi:10.1080/02699200400026918.
• Chadwick KA, et al. J Voice. 2021;doi:10.1016/j.jvoice.2020.03.008.
• D’haeseleer E, et al. J Voice. 2012;doi:10.1016/j.jvoice.2011.11.011.
• Huang G, et al. J Clin Endocrinol Metab. 2015;doi:10.1210/jc.2015-1669.
• Lin RJ, et al. JAMA Otolaryngol Head Neck Surg. 2020;doi:10.1001/jamaoto.2020.2174.
• Schneider B, et al. Menopause. 2004;doi:10.1097/01.GME.0000094192.24934.46.

For more information:

Yael Bensoussan, MD, MSC, can be reached at yaelbensoussan@usf.edu.