Academic journal article Journal of Singing

The Effects of Hormonal Contraception on the Voice: History of Its Evolution in the Literature

Academic journal article Journal of Singing

The Effects of Hormonal Contraception on the Voice: History of Its Evolution in the Literature

Article excerpt

[Modified from J. Rodney and R.T. Sataloff, "The Effects of Hormonal Contraception on the Voice: History of its Evolution in the Literature," Journal of Voice 30, no. 6 (November 2016): 726-730; with permission.]


The fluctuation of hormones in the menstrual cycle has significant effects on the voice.1 Singing teachers should be familiar with the vocal effects of hormones and of hormonal medications such as oral contraceptives (birth control pills), especially in light of recent changes in their chemistry and effects. Vocal symptoms, known as dysphonia premenstrualis, accompany the better known symptoms of premenstrual syndrome (PMS) during the luteal phase of the menstrual cycle.2 The most common symptoms of dysphonia premenstrualis are difficulty singing high notes, decreased flexibility, huskiness, fuzziness, breathiness, decreased volume, difficulty bridging passaggios and intonation problems.3 Davis and Davis concluded that, on average, singers experience 33 general symptoms of PMS and 3 symptoms of dysphonia premenstrualis.4 Chae et al. showed that approximately 57% participants met the DSMIV criteria for PMS and also had acoustic evidence of dysphonia premenstrualis, whereas the PMS-negative group did not.5 The risk of vocal stress and possible damage during the premenstrual period led many European opera houses to offer singers contracts that included "grace days" during their premenstrual period. This accommodation is no longer followed in Europe and was never practiced generally in the United States.6

The mechanisms that cause these symptoms lie not just in the actions of the hormones themselves, but also in the cyclic fluctuation of hormone levels. The actions of the hormones on the vocal folds can be correlated with their effects on cervical mucus production. Cervical mucus in the preovulatory or follicular phase is thinner and slippery to aid insemination, while in the premenstrual or luteal phase it is thicker and more viscous.7 Receptors for estrogen and progesterone have been identified in vocal fold mucosa.8 Increased estrogen causes increased vocal fold mucus secretions and reduced mucosal viscosity and may increase vocal fold mass or thickness. Estrogen levels are highest in the follicular phase or preovulatory phase. Increased progesterone causes decreased mucus secretions, dehydration of the mucosa and lamina propria, increased mucous viscosity, associated with decreased mass or thinning of vocal fold mucosa. Progesterone levels are highest during the premenstrual phase or luteal phase.9 Dehydration and thinning of the vocal folds in the premenstrual phase contributes to the symptoms of dysphonia premenstrualis.

The Physiology of the Menstrual Cycle

The menstrual cycle begins with approximately 5 days of menstrual flow. Both estrogen and progesterone levels are low during the menstruation phase. The follicular phase follows, in which the level of estrogen increases daily until day 14 when ovulation occurs, triggered by a surge in luteinizing hormone (LH). The luteal phase follows in which the estrogen level quickly decreases to mid-level. It plateaus there until the end of the cycle, when it drops quickly prior to menstrual flow. Progesterone remains low after the fifth day of menstrual flow. After ovulation, the progesterone level rises steadily to reach a peak halfway through the luteal phase. Then progesterone starts to decrease and reaches its lowest level prior to menstrual flow.10

The Physiology of Oral Contraception

Oral contraceptive pills (OCPs) reduce the overall fluctuation of hormones during the menstrual cycle that results in the depression of ovarian function. They function by feedback inhibition of hypothalamic secretion of gonadotropin releasing hormone (GnRH). The progesterone derivative also suppresses LH secretion from the anterior pituitary, which prevents ovulation. The estrogen derivative suppresses FSH secretion from the anterior pituitary, which inhibits follicle growth prior to ovulation. …

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