This paper identifies the most common changes encountered by the female voice as a result of menopause and explores their causes and possible strategies to help mitigate the impacts.
Introduction
The global population, due in some part to improved medical practice and falling fertility rates, has seen the older segments of society grow faster than at any other time (Okasaki et al, 2018, Filipa et al. 20221, World Health Organisation, 2010, Ortman and Velkoff, 2014). These findings indicate that this area of the market has increased and that the voice teacher is ever-more likely to encounter women experiencing menopausal voice change (Mitton, 2020).
Voice change in menopausal women has become a growing area of interest and relevance in my own professional life in my capacity as director of various ensembles which include many women aged over 50 and an increasing number of postgraduate students at the University where I am vocal tutor and in my private studio. I am frequently asked for advice to help mitigate menopausal voice change but have very little specialist knowledge upon which to draw. I reviewed a significant amount of recent research but found that there was often a large inconsistency in key findings (Shankar et al, 2022, Fiuza et al, 2023).
The overall aspiration for this project is that it will help me improve my knowledge and teaching so that I can better help and advise the women whom I encounter who are experiencing menopausal voice change and to design and present groups sessions to empower and educate singers and teachers through a potential programme of workshop sessions.
Context
The majority of the menopausal singers that I encounter in my professional life view their changing voices with pessimism and gloom. The common narrative of much of the literature that I have reviewed for this project is one of inevitable decay for the menopausal voice, loss of vocal function and a list of likely symptoms each as unpleasant as the last which will potentially manifest themselves at any point in the near future.
The aim of this project is to identify strategies to help me deliver sessions to help singers and teachers understand menopausal voice change, therefore I am seeking to find research with a positive outlook that will help me improve the lives of the women who need support. Sataloff, 1987 states that the inevitable decline in vocal function is open to challenge and that many aspects of vocal health and efficacy can be maintained well into the seventh decade and beyond. There is some research that identifies strategies to help women improve the symptoms of voice change and to adopt a more positive outlook (Edwin 2010 and Ferraz et al, 2013).
I want to focus on the potential for group sessions in addition to one-to-one tutorials as a means of delivery for my research findings and identified strategies because facilitating an increased interaction with others with similar problems can promote improved wellbeing, individual vocal growth and perpetuate positive vocal habits (Rayapati, 1971).
The aim of this study is:
· To help singing teachers, choral directors and singers understand the most common symptoms of the menopausal voice and to suggest strategies to help those who are suffering that could potentially be delivered through sessions with individual singers, choirs and other vocal groups in South Wales.
The objectives of the study are:
· To review the literature relating to symptoms experienced by the voice as a direct result of menopause.
· To help me understand and rationalise my own knowledge and what I have learned, building on my existing skills as a vocal practitioner and musical director.
· To reflect critically on my research findings to help me prepare for potential sessions with my own groups, students and other singers in my local area.
Learning outcomes for the project are:
· To understand more fully the most common symptoms often encountered by the menopausal voice.
· To broaden my knowledge and understanding of strategies to help me as a teacher to support women struggling with menopausal voice change.
· To evaluate the research findings and strategies that I have discovered which are relevant to my field of study.
· To identify how what I have learned could potentially help my practice and how effectively it could be applied in a range of settings to help others.
Time scale of project
· Decide on the subject of project: to be completed by 30/11/2023
· Decide on aims, objectives and research parameters: to be completed by 30/11/2023
· Review of literature: 15/11/23-15/02/24
· Writing up the project:01/01/24-18/03/24 (first draft to be submitted 04/03/24)
· Revision of project, amendments, bibliography: to be completed by 18/03/24.
Methodology
I decided that the majority of my research will be qualitative but I will refer to findings from some quantitative research for example surveys and controlled studies where this helps contextualise my findings and provides a greater scope for insight and a wider perspective (McKim, 2015). Berg (2001) advises that the type of data that will be generated from qualitative research needs to be primary consideration when planning the research design. Furthermore, the presentation of data should always be textual and never reduced to numerical form. Any data that I collect from quantitative sources will be expressed within the main body of text and not in mathematical formats.
Denscombe (2014) notes that the choice of which research methods will work best for any project is ‘problem-driven’ and that the best means of organising and presenting data should be the primary factor when making decisions at the start of any research project. When selecting a method to collect, analyse and report data, selecting either a quantitative or qualitative approach is one of the most fundamental decisions to be made when constructing a research design. Mackenzie and Knipe (2006) argue that the two methodological approaches are frequently referred to too informally in academic texts, often causing confusion about the purity of each method as a stand-alone means of data collection which, they suggest, is impossible. Bell (2005) suggests that, whilst a research project may rely more on one means of data collection, it may be possible for example, for a project to draw on both methods. I feel that my own research will be much more aligned to a qualitative approach because I want to understand the results of my research and describe them fully.
Searches fell broadly into the following topics:
· Menopause, symptoms of menopause
· Menopause and the singer, menopause and the voice/singing
· Teaching voice/singing to singers during/after menopause
· Strategies to help/teach the voice during/after menopause
By collating lists of the primary symptoms of menopausal voice change, I was able to identify those most commonly encountered by women. This helped define my field of enquiry and refine my research parameters. The purpose of the literature review was to understand the most common symptoms of voice change during menopause but also to explore possible strategies to employ to help women. Because I was seeking to improve the quality of potential practice in supporting those with menopausal voice change, my research could be described as applied research (Merriam and Tisdell, 2016). My research findings will be the basis of devising and informing a strategy to deliver help to menopausal women in group sessions, therefore elements of my research methods could also be described as inductive. Inductive research analysis begins with the findings of the study and uses the data to formulate theories and concepts (Locke, 2007).
Primary sources constituted the majority of my research findings. I used key words in my searches (listed above) using a variety of resources including the NATS website (https://www.nats.org) for access to Journal of Singing, access to the university library and google scholar. I also had a variety of physical books in my own collection to which I was able to refer.
The primary sources upon which I drew for specific scientific data are mostly papers written since the turn of the millennium and peer-reviewed. I understand, as an Estill practitioner, that much of the research upon which I rely on a daily basis is not peer-reviewed and could be considered by some to be grey literature. This course has taught me to cast my net more widely and with more discernment to consider fully the validity, relevance and credibility of my sources. There is much inconsistency in research findings on the menopausal voice (Filipa, 2022, D’haeseleer, 2012) and so I will consider carefully the validity of each source.
Exclusions:
· I sought only to identify the symptoms of menopausal voice change and strategies that could be used by the voice practitioner to help mitigate them: not potential treatments or their effects. I avoided any reference to hormone replacement therapy (HRT) and any research that described the symptoms of women who had undergone any kind of medical or hormonal treatment.
· I was seeking to identify vocal symptoms of the entire menopause. Therefore, I mostly treated the specific stages of perimenopause, menopause and post menopause as one event. I have referred to a specific stage of menopause when it is relevant to the research. Fiuza et al, 2023 reports that much relevant literature categorises women in various stages of menopause which is problematic because of variations in symptoms and the age at which they manifest themselves.
Literature Review
This project comes from a desire and a necessity to understand more fully the vocal changes experienced by women during menopause and to identify strategies to support them that could be used in my lessons and wider, group sessions. I aim to share my findings and present them in a format that I will design to enable others to use my work for the benefit of women struggling with menopausal voice change. Resources readily available to menopausal women rarely include information on changes in the voice or advice on how to mitigate the changes (Bos et al, 2020, Schneider, 2004). Preserving vocal quality is important to many postmenopausal women and it is important to understand the impact of menopause on the voice (D’haeseleer et al, 2009, Price, 2022)
Prior to this project, I knew nothing about menopause despite teaching at least fifteen menopausal or postmenopausal women each week in my private studio and at the University School of Music. I also have contact with at least 50 women over the age of 50 on a weekly basis as singers the vocal groups that I direct. The majority of my students are aged 18-30 and I realised that I was teaching the older women as if they were in the younger age bracket. I found that the older voices were not able to respond to some of my suggestions or expectations. For the first time, I realised that the Estill Voice Model, which I use with every student I teach, just was not helping me or the older women because they were not able to support the level of physicality that I expected from them. This study is designed to equip me with a greater understanding of six of the most commonly experienced symptoms of menopausal voice change and to identify strategies to help each problem.
Key terminology: menopause, sex hormones,
1. Loss of vocal flexibility and agility
Elliott, 2017 identified that 79% of 130 post-menopausal women singers who were surveyed had perceived a reduction in their vocal flexibility. Boulet, Oddens, et al., 1995, identified that 72% of the 48 menopausal, trained singers that were surveyed identified a loss of suppleness in their vocal folds. Both surveys indicate that a significant number of women experience a loss of suppleness and flexibility.
Weiss, 1988 reports that women with lower levels of oestrogen have a reduced ability to perform motor tasks that require speed and exactness. Singing coloratura requires fast movements in the vocal organ and a high level of exactness and accuracy.
The presence of oestrogen is fundamental to preserving the good health, elasticity and structural integrity of the vocal folds Abitbol et al, 1998 and Boulet et al. 1996). In postmenopausal women, in which the levels of oestrogen have declined significantly, the reduction in malleability and flexibility results in a reduced ability to change the mass, tension and length of the vocal folds and therefore phonation at the extremes of the vocal range becomes relatively limited. Sataloff et al. 1996, states laryngeal cartilages begin gradually to turn to bone during menopause. The arytenoid cartilages play a fundamental role in determining the mass, tension and length of the vocal folds (Steinhauer, 2017) and so the potential implications of them losing their integrity for the singer to move her voice quickly are profoundly negative.
Strategies for the teacher
Price 2022, finds that exercises can actually improve agility in the post-menopausal voice even when the voice has deteriorated and the vocal folds have become stiffer. The regular singing of scales, even if of a limited range, can help develop agility in the voice. Perhaps starting at a moderate tempo with a range of a third, fifth or octave could be a gentle start before increasing the tempo and range of the scales.
2. Hoarseness and frequent throat clearing, dryness of the voice
Martins et al, 2014 identifies hoarseness of the voice and frequent coughing as one of the most common symptoms of the post-menopausal voice.
Raj, Gupta et.al 2008, observe that menopausal women often experience frequent throat clearing and coughing and that it is more noticeable to women who are trained singers or professional voice users as they are in closer touch with their vocal health than non-professional voice users. Sataloff et al. 1997, suggest that the edges of the vocal folds become less smooth during menopause which might give the perception of irritation which promotes frequent throat clearing – even if it is not actually necessary.
Amir et al, 2004 suggests that thickening of the vocal folds after menopause is attributed to oedema (fluid trapped inside body tissue) and that these changes may result in hoarseness of the voice (Sataloff et al, 1997). This thickening of the vocal folds is not experienced by all women and often the vocal folds thin and deteriorate as part of the natural process of tissue and muscular atrophy (Sataloff, 1987).
Sataloff, 1996 notes that the vocal folds undergo several structural changes during the reduction of oestrogen as a consequence of menopause which include swelling due to absorbing water, vascular congestion and increased mass. The folds experience these changes independently and they may become asymmetrical. When the vocal folds do not adduct in a symmetrical, manner, or in the manner to which the women has become accustomed over several decades of using her voice, the urge is to clear the throat in an attempt to reset the stability of her voice.
The findings above cite a range of causes for the symptoms but it is clear that there is more research to be done to reach a consensus.
Strategies for the teacher
De Maio, 2013 suggests the use of straws, humming and singing /i/ and /u/ vowels to promote stability of the vocal folds during the closed phase. Fiuza et al, 2023 recommends gentle phonation with minimal contact between the vocal folds.
Kendall, 2007 and Gracco et al, 1989 observes that the menopausal woman will experience a reduction of salivary secretion and mucosal glands which give the perception of a less lubricated voice which will lead to coughing and clearing of the throat. A disciplined and consistent approach to hydration is recommended to help alleviate the symptoms of at least eight glasses of water a day.
A review of medication is recommended for women experiencing hoarseness as a consequence of menopause. Tseng, 2010 advises that some antihistamines can cause mucosal drying of the vocal folds. It is sensible to conclude that the chronic cough mentioned in the research is more likely to manifest itself in a voice that is already experiencing dehydration. The literature does not specify if the aggravating medication mentioned in the report is inhaled or ingested and so the women would be advised to speak to a medical practitioner for further advice.
Price, 2022 suggests that the reduction in salivary secretion in the menopausal voice will cause it to require more frequent respiration during longer phrases. Therefore, more breathing points within a song will potentially prevent the voice from feeling dehydrated and hoarse.
3. Loss of range and a narrowing register
Raj, Gupta et.al 2008 compares the loss of frequency range of postmenopausal women and women of ovulating age (menacme) at various points during their menstrual cycle. The presence of ‘sex hormones’ namely oestrogen and progesterone, were found to present a wider range of variation of mass of the vocal folds, amplitude, range and hydration however, these changes seemed to follow a mostly predictable and consistent pattern as part of the menstrual cycle. However, the menopausal voice was found to have an increased amount of breaks which reduced consistency across the vocal range. Moreover, the vocal range of the forty postmenopausal women who participated in the study was found to be narrower than ovulating women due to the reduction in oestrogen and resulting fluctuating mass of the vocal folds and the increase in testosterone and potential for oedema.
Abitbol et al. 1989 and Caruso et al, 2000 discovered that there was a significant similarity in the way that the epithelium of the vocal folds and cervix responded to changes in hormone levels during cytological smear tests. This suggests that the cervical and laryngeal tissues are almost equally susceptible to hormonal change during menopause. The study concluded that the larynx was a ‘target organ’ for hormones. Furthermore, a study of normal laryngeal tissue (Ferguson at al, 1987) identified progesterone and oestrogen receptors in all laryngeal muscles.
Elliot, 2017 notes that menopausal women experience increased loss of access to both the higher and lower registers. Boulet, Oddens, et al., 1995, identified that 69% of the 48 menopausal, trained singers that were surveyed identified a loss of their top registers.
De Maio and Fox, 2019, found that some postmenopausal singers found that their lower registers developed problems which resulted in a reduced ability to phonate effectively, but some found that their lower registers became fuller and stronger: this may be due to oedema (mentioned above).
Abitbol et al, 1999 found that trained high sopranos experienced a greater loss in their high registers and that trained mezzos identified their lower range as being more problematic.
The findings above have a common narrative of there being no consistent pattern from voice to voice. The only identifiable trend is that there is a perceptible loss or change in the vocal range of menopausal women and that hormones, which are inextricably linked to the condition of the vocal folds, also play a fundamental role.
Strategies for the teacher
Price, 2009, found that over a 10 week period of weekly sessions, that the vocal range of the post-menopausal participant in her study extended significantly. This was achieved through pitch slides over small intervals, typically a third, which were expanded through the 10 week period. Staccato singing was also found to help extend the range upwards however no explanation was given why this might have helped the participant extend her range.
Miller, 1996, advocates the use of vocalises to extend the range of the voice and stresses the importance of considering the key and difficulty to suit the voice. This could limit the teacher in a group setting where there were singers with different vocal ranges and varying levels of competency. He also suggests that exercises for agility can also be useful to extend the range. As the focus of this project is the menopausal voice, it may be that I could design a range of short, simple vocalises or scalic patterns that could be presented in a range of keys to suit the individual singer.
4. Loss of dynamic intensity/projection
The vocal folds in the postmenopausal voice deteriorate and thin which results in a loss of elasticity, mass and subsequently a reduced ability to produce a more intense, louder and projected dynamic of the premenopausal singer (Johnson and Brunssen, 2018). They conclude that the loss of mass of the vocalis muscle (sarcopenia) as being inevitable and that agility is reduced and breathiness and vibrato is increased as the voice becomes menopausal. Sataloff, 2000 finds that the vocal folds deteriorate and thin in mass as a result of menopause which results in them becoming stiffer and experiencing a loss in elasticity. The glottal chink, so common in female voice mutation during puberty, is often found in the menopausal larynx as the vocal folds lose their ability to completely adduct due to a loss in mass. The result of these changes can manifest themselves in the voice with a perceptible increase of breathiness in the voice. Estill 2006 concludes that breathiness in the voice (identified as falsetto quality in the Estill Voice Model) significantly reduces the ability of the voice to project effectively because the vocal folds are stiff and do not adduct fully during the closed-phase of phonation.
Elliott, 2017 identified that 79% of 130 post-menopausal women singers who were surveyed who had perceived a reduction in their vocal power and dynamic intensity during peri-menopause. However, D’haeseleer, 2011 reports that these changes were also found in a study of pre-menopausal women and that aging often attributed to menopause may actually begin before its onset. Furthermore, (Sataloff, 1987) reports documenting changes in the voice from the age of thirty. Ferraz, 2013 concludes that, after conducting a study of 106 women divided into two groups of women (group 1 with ovarian function and group 2 consisting of postmenopausal women), hormone levels alone are the drivers for voice change regardless age. Different studies on the changes of the vocal folds during menopause often arrive at different conclusions and there is significant disagreement amongst researchers (D’haeseleer, 2009).
Strategies for the teacher
Edwin, 2012), suggests embracing the changes encountered by the voice. For example, to counteract the loss of vocal intensity, he suggests that the older singer can potentially bring a level of emotion to a performance through life experience which is not possible for the younger singer. The implications for the teacher could be that a more suitable choice of repertoire, one that allows for greater characterisation of the voice, might be more approachable and appropriate for the singer with a loss of dynamic intensity.
Miller (1995) notes that a ‘slight glottal onset’ should be used when singing exercises to promote closer approximation of the vocal folds and that the aspirate onset should be avoided. This will promote vocal fold adduction and reduce the breathiness in the voice. Williams (2019) also suggests using a gentle glottal onset to begin phonation as a means of eliminating breath during vocal fold closure. The effectiveness of this approach is supported by the fact that glottal onset promotes closure of the vocal folds before the beginning of exhalation theoretically eliminating breath from the sound (Steinhauer & Klimek 2017).
Gaskill and Erickson (2008) suggest that a voiced lip trill can help to regulate breath flow and create pressure for efficient phonation which is neither to constricted or breathy. Cordeiro, Montagnoli et al. (2012) found that the lip trill benefitted less trained singers more than the professionals who participated in their study which might be useful for women who are less experienced. Titze (2006) concludes that using fricatives, humming and semi-occluded vocal postures can promote a greater efficiency in terms of supra and intra-glottal pressure.
Samuelson (1999) suggests that it might be a better strategy to approach addressing the speaking voice first. Furthermore, (Gill and Herbst, 2016) suggest that voice building exercises should originate from a comfortable posture without tension or unnecessary intensity.
To counteract thinning of the vocal folds, (Sataloff, 2000, Allen, 2006) suggests that regular phonation through basic scales or other daily simple vocal exercises may bulk up the vocal folds which could be a very positive intervention for the singer experiencing a loss of vocal projection. Sataloff, 1987 states that a range of interventions exist and that the most important one is that frequent use of the vocal organ is the primary driver for muscular development, conditioning, maintenance and reduced atrophy. Price, 2013 reports that a study of the benefits of 12 weeks of daily singing by post-menopausal women included reduced tension in the larynx, improved resonance and more positive self-perception of the voice.
The gentle singing of sustained notes according to (Cotrell, 2015), develops muscle tone in the vocal organ. Singing a sustained note with varying dynamics, however limited the range may be, has been found to help the voice with loss of dynamic intensity (Zeigler and Hapner, 2013).
5. Changes in vibrato
Reid, 2007, observes that often the change in the vibrato as a result of the menopause can be the most noticeable and identifiable symptom of voice change. He observes that the vibrato can become to wide, slow or fast. Changes in vibrato can affect the confidence of the singer more readily than perhaps internal, less identifiable changes such as thinning of the vocal folds (Raming, 1983).
Shankar, Raj et al. 2022, suggest that the structural changes in vocal folds of menopausal women are due to hormonal fluctuations. The manner in which the vocal folds behave during the closed-phase during phonation is likely to result in a reduced ability to control contact and subsequently the behaviour of the response to the air flow when trying to produce and manipulate a consistent vibrato. Furthermore, it was found that during the menopause, laryngeal muscles suffer a loss of mass, vocal folds become thicker and lose their fibral elasticity resulting in a stiffening of the vocal organ and subsequent reduced ability to produce vibrato during phonation.
Elliott, 2017 identified that 71% of 130 post-menopausal women singers who were surveyed who had perceived a negative change in their ability to produce vibrato and also an awareness of increased ‘stiffness’ of their vocal organs.
However, there is a fundamental disagreement between the findings of two prominent studies about how the outer layers of the vocal folds change as a result of menopause. Hirano et al., 1998, found that the outer layers (epithelium and superior lamina propriar) of the vocal folds experienced a thickening whilst Ximenes Filho et al., 2003 discovered the opposite; that there was evidence of thinning. Brunssen, 2018 concludes that, whilst there is disagreement amongst studies, there is broad consensus that changes in the biomechanical composition of the vocal folds change with age and during and after the menopause which, as a result, have a profound, yet inconsistent change on vibrato.
Strategies for the teacher
Brodnitz (1983) concludes that no two voices are the same and, as reported above, the changes in vibrato as a result of menopausal voice change can be very different. It is important to approach each voice on an individual basis, find its natural response and to avoid trying to teach it to conform to the perceived aesthetic preference of the singer (Austin, 2017).
Because vibrato is a perceptible quality of the voice, women are potentially more likely to be self-conscious about the changes as a result of menopause and may seek to try and manufacture a sound that they find acceptable. Best practice (Mitton 2020) suggests, is to encourage the singer to focus on what they can do right now and accept that underlying weaknesses can improve with time. Ferraz et al, 2013, suggests that vocal aging should be viewed by teachers and singers as a natural part of aging and that voice change is not a disorder but a process.
Sataloff, 1987 suggests that it is the loss of elasticity of the lungs and the deterioration of the abdominal muscles that undermine the support required for consistent vibrato. He suggests that increased, regular exercise to improve respiratory and abdominal health combined with vocal tuition will have a direct, positive impact on developing or maintaining vibrato.
Bos et al, 2022 notes that a change in vibrato could result in a completely new vocal identity for the post-menopausal women. This might facilitate the need to explore new song repertoire and even different genres.
6. Lowering of the voice
Whilst studies have identified a rise in the fundamental frequencies of males aged over fifty, there seems to be a wide consensus that the peri-menopausal and post-menopausal female voice typically experiences a lowering and increased instability of fundamental pitch (Shipp and Hollien, 1969, Wolcox and Hori, 1980, Ramig, 1983, Linville and Fisher, 1985, Linville, 1987, Decoster, Debruyne, 1997). Bos, Bozeman et al., 2020 claim that the lowering of the singing voice as a result of menopause is the most common symptom manifested in the voice of the trained singer.
Raj, Gupta et.al. 2008, identify the mean fundamental frequency of women of a reproductive age as being 231 Hz (B flat 3) but the mean fundamental frequency of the postmenopausal voice as being a whole tone lower (27Hz) at 204 Hz (A flat 3). However, Shankar, Raj et al. 2022 suggest that the change in the fundamental frequency of the voice as a result of menopause is only 14 Hz: approximately half the findings of the study quoted above. Ardura, 2020 concluded that the drop in the voices of women who were vocal professionals as a result of menopausal voice change was relatively small. Shankar et al, 2022 suggests that weight could also play a role in the amount of lowering of the voice post-menopause and that women with lower body mass index experienced a greater lowering of the voice than those with higher BMI.
Titze, 2011 suggests that changes in the fundamental frequency of the female voice during menopause may not be due simply to the biological event in isolation or even follow generic trends, but perhaps vary according to the stiffness and mass of the vocal folds of individual women. He does acknowledge that the lowering of fundamental pitch during menopause is more likely a result of an increased stiffness of the vocal folds and reduced muscularity rather than a change in mass.
However, McGlone & Hollien, 1963, suggest that the female voice lowers from a mean fundamental pitch of 225 Hz (A3) to 195 Hz (G3) naturally over a period of seventy years from the twentieth to the ninth decade. These findings, which represent a similar amount of change (a major second) as Gupta et. al 2008 could suggest that the female voice follows a lifelong and inevitable trajectory of lowering fundamental pitch. Moreover, the implication could be interpreted that the contribution of the menopause is only a part of the lifelong lowering of the voice and that the exact extent of the effects caused on the voice as a result of menopause vary between different women.
Strategies for the teacher
Vocal rehabilitation should start with exercises focusing on respiratory support to stabalise the fundamental frequency of the voice (Ramig at al, 2001). These could include short periods of walking/jogging on the spot to improve vascular fitness and stamina before moving onto specific breathing exercises which might include torso anchoring as described in Steinhauer et al, 2017.
Sovani, 2010 suggests that the lowering in fundamental frequency of professional voice users (teachers, public speakers and similar) is often negligible. This implies that voices that are used frequently are more resilient to change as a result if menopause. Ramig et al, 2014, recommends exercises that promote glottic closure to help stabalise the fundamental frequency of the voice. As mentioned above, regular vocal use was found to bulk up the vocal folds which promotes greater closer during the closed phase. Semi-occluded vocal tract exercises or gentle humming on sustained notes through the vocal range would potentially be helpful. If, as suggested above, muscular atrophy and lack of vocal use are responsible for the lowering of the voice then it is clear that regular, sustained vocal exercise could potentially help the singer rediscover her previous fundamental frequency.
Future recommendations
In the literature that I had discovered, I could find no strategies that suggested the use of the siren. Estill (2006) states that the siren promotes freedom and helps ensure stability, consistency and flexibility across the vocal range. I was surprised that no literature linking the siren directly to improving flexibility existed. It would be a possible area of future research for me to investigate the benefits of performing the siren to the menopausal voice.
Much of the literature above identifies the symptoms of the menopause on the voice but not the specific causes. I found it hard to identify and link causes and symptoms in some of the reports in which symptoms were just listed including (FIuza et al, 2023; Shankar et al. 2022; Martins et al, 2014; Raj et al, 2008). Sataloff (1997) briefly explains the physical manifestations of the changes in the vocal fold but not the specific cause. Too often the cause is just given as being the menopause. It would seem sensible to explore the absolute root of the vocal symptoms to design strategies to mitigate them. It is clear, from the literature that I found, that more research is needed into the exact cause of specific symptoms.
Several reports highlighted the different experiences of women who were trained voice professionals and those who were not (Ardura, 2020; Cordiero et al, 2012; Raj et al, 2008). This topic of inquiry could potentially be an area of future research to help offer pre-menopausal women training before the onset of menopause as a means of preventative intervention.
Limitations of this study are principally twofold:
· inconsistency of findings between several studies on the same topic including (Fiuza et al, 2023; Shankar et al, 2022). Filipa (2022) and D’haeseeler (2009) acknowledge the frequent disagreements in research findings on menopausal voice change. Key factors in undermining consistency between studies include: varying sizes of samples of women; focus on different age ranges and stages of menopause; lack of consensus of boundaries of peri/menopause/post menopause; categories of women (trained voice users versus non trained voice users); range of symptoms and specific definitions of symptoms for example hoarseness versus dryness.
· there is no absolute parameter for the onset of menopause or consistency amongst the demographic that can identify the transition from each phase to the next. Every women and every voice is different and so the opportunity to arrive at a definitive set of data outcomes is almost impossible. I had hoped that this project would provide immutable findings that would prevail against rigorous scrutiny. However, at best, I have been able to identify some key trends.
References
Abitbol, J., Abitbol, P., Abitbol, B. (1998) Sex Hormones and the Female Voice. Journal of voice, Vol. 13, no. 3 (424-446)
Allen, S. (2006) Menopause and the femal singer: A survey of physical and psychological changes, and of the available treatments and how these affect the vocal performer. MA Thesis, University of Cape Town https://www.open.uct.ac.za/handle/11427/7779
Bell, J. (2010) Doing Your Research Project: A guide for first-time researchers in education, health and social science. 4th ed. Maidenhead: Open University Press.
Berg, B. (2001) Qualitative research methods for the social sciences. 4th ed. Boston: Allyn and Bacon.
Booth A., Sutton, A., Clowes, M et al. (2022) Systematic Approaches to a Successful Literature Review. 3rdEdition. London: SAGE Publications Ltd.
Bos, N., Bozeman, J., Frazire-Neely, C. (2020) Singing Through Change: Women’s Voice in Midlife, Menopause and Beyond. Suquamish, WA: StudioBos Media USA
Boulet M. J., Oddens, B. J., (1995) Female voice changes around and after the menopause – initial investigation. Maturitas Journal of the Climacteric and Postmenopause, 23 (1996) 15-21
Brodnitz, F. (1983) On Change of the Voice. Journal of Singing, Nov/Dec 1983, pp. 24-26
Brunssen, K. (2018) The Evolving Singing Voice. San Diego: Plural
Caruso, S., Roccasalva, I., Sapienza, G. et al. (2000) Laryngeal cytological aspects in women with surgically induced menopause who were treated with transdermal estrogen replacement therapy. Fertil Steril 2004: 74 (1073-1079)
Chapman, J. (2006) Singing and Teaching Singing: A Holistic Approach to Classical Voice, Plural Publising Inc, San Diego
Cottrel, D. (2015) Building Vocal Strength with Sustained Tone Warm-Ups.
DeMaio, B. F. (2013) The effect of menopause on the elite singing voice: singing through the storm. Doctoral thesis, Shenandoah University. https://www.academia.edu/39095271/The_Effect_of_Menopause_on_the_Elite_Singing_Voice
Denscombe, M. (2014) The Good Research Guide. 5th ed. Maidenhead: Open University Press
D’haeseleer, E., Depypere, H., Claeys, S., et al. (2009) The menopause and the female larynx, clinical aspects and therapeutic options: A literature review. Maturitas Journal of the Climacteric and Postmenopause, 64 (2009) 27-32
Edwin, R. (2012) Voice pedagogy for aging singers (including the author) Journal of Singing, 68, 561-563
Elliot, M. (2017) Singing Through Menopause: Reactions and Responses – Survey Results. Journal of Singing, January/February 2017. Vol. 73, no.3 (267-278)
Estill, J. (2006) Estill Voice Training Level One: Figures for Voice Control. Estill Voice Training Systems International, LLC, 2006
Ferguson, B. J., Hudson, W. R., McCarty, J. S. (1987) Sex steroid receptor distribution in the human larynx and laryngeal carcinoma. Otolaryngol Head and Necl Surg 1987: 113 (1311-1315)
Ferraz, P. R. R., Bertoldo, S. V., Bethania, M. (2013) Voice parameters and voice related quality of life in adult women with and without ovarian function. The Journal of Voice, 27, 355-360
Filipa M. B., Ardura, D. (2022) What Voice-Related Metrics Change With Menopause? Systematic Review and Meta-Analysis Study. Journal of Voice. Vol. 36, no. 3, 2022
Fiuza, M. B., Sevillano, M. L., Filipa, M. B. (2023) Singing at menopause: a systematic review with pedagogical implications. Musicae Scientiae, vol. 23 (193-217)
Gaskill, C. S., Erickson, M. L., (2008) The Effect of a Voice Lip Trill on Estimated Closed Glottal Quotient. Journal of Voice, 22 (634-643)
Gibbs, G. (1998) Learning by Doing: A Guide to Teaching and Learning Methods. Oxford Brooks University
Gill, B. P., Herbst, C. T. (2016) Voice Pedagogy: What do we Need? Logopedics Phoniatrics Vocology 41, no. 4 (2016)
Gracco, C., Kahane, J. (1989) Age-related changes in the vestibular folds of the human larynx: A histomorphometric study. Journal of Voice. 1989. Vol 3, (204-212)
Hirano, M., Kurita, S., Sakaguchi, S. (1989) Ageing of the vibratory tissue of human vocal folds. Acta Otolarygologica, 107 (428-433)
Kendall, K. (2007) Presbyphonia: a review. Curr Opin Otolaryngol Head Neck Surg 15(3) (341-350)
Linville, S. E. (1987) Maximum phonational frequency range capabilities of women’s voices with advancing age. Folia Phoniatr, 1987: 37 (297-301)
Martins, R. H. G., Pessin, A., Nassib, D. J., et al. (2015) Aging Voice and the Laryngeal Muscle Atrophy. Laryngoscope 125: November 2015
McGlone, R., Hollien, H. (1963) Vocal pitch characteristics of aged women. J Speech Hear Res. 1963:3 (164-170)
McKim, A. (2015) The Value of Mixed Methods Research: A Mixed Methods Study. Journal of Mixed Methods Research, Vol 11, Issue 2, 2017.
Merriam, S., Tisdell, E. (2016) Qualitative Research: A Guide to Design and Implementation. San Francisco: Jossey-Bass
Miller, R. (1996) On the Art of Singing. New York: Oxford University Press; 1996.
Mitton, D. (2022) Habilitation for the Aging Avocational Singer. Journal of Singing, January/February 2022, vol. 78, no.3 (347-354)
Locke, E. (2007) The Case for Inductive Theory Building. Journal of Management, Vol. 33 No. 6, December 2007 pp. 867-890
Okasaka, G. P., Korn, J. C., Neto, N. A. (2019) Laryngostroboscopic findings in postmenopausal women. Clinical and Experimental Obstretics and Gynaecology Journal, June 2019
Ortman, J. M., Velkof, V. A., (2014) An aging nation: the older population in the United States
Price, K. K. (2013) The effect of a singing protocol on identified vocal inefficiencies of a post-menopausal singer: A case study. The Phenomenen of Singing, 7, (118-130)
Price, K. K. (2022) Still singing after all these years. International Journal of Research in Choral Singing (2022) Focus on Vocal Health 220-241
Raj, A., Gupta, B., Chowdhury, A., et al. (2008) A Study of Voice Changes in Various Phases of Menstrual Cycle and in Postmenopausal Women. Journal of Voice. Vol 24, no. 3 (363-368)
Ramig, L. O., Gray, S., Baker, K. et al. (2001) the Aging Voice: A Review, Treatment Data and Familial and genetic Perspectives. Folio Phoniatr Logop 2001, 53: 252-265
Rayapati, S. (2008) Teaching Reaches Out: Class Voice and the Aging Singer. Journal of Voice. Vol. 64, no.5.
Reid, C. (2007) Vocal Mechanics and the Cultivation of Listening Skills. https://corneliusreid.files.wordpress.com.2014/08vocal-mechanics-and-listening-skills-for-web. Accessed 28/02/24
Sataloff, R. T. (1987) Common diagnoses and treatments in professional singers. Ear, Nose and Throat Journal, 1987: 66, 278-88
Sataloff, R. T. (1987) The Aging Voice. Journal of Singing, January/February, 1987, 20-21
Sataloff, R. T. (1996) The Effects of Menopause on the Singing Voice. Journal of Singing, March/April 1996 (39-42)
Sataloff, R. T., Rosen D. C., Hawkshaw M., Spiegel J. R. (1997) The three ages of voice: the aging adult voice. Journal of Voice, 1997: 11, 156-160
Sataloff, R. T. (2000) Vocal Aging and Its Medical Implications: What Singing Teachers should Know Part 1. Journal of Singing, September/October 2000 (29-43)
Sataloff, R. T. (2000) Vocal Aging and Its Medical Implications: What Singing Teachers should Know Part 2. Journal of Singing, November/December 2000 (23-37)
Schneider, B. (2004) Voice Change is Overlooked. Menopause 11 (March/April 2004) (151-158)
Shankar, R., Raj, A., Rathore, P. K., et al. (2022) Menopause and its Effect on Voice. Association of Otolaryngologists of India, December 2022
Sovani, P. (2010) Comparison of postmenopausal voice changes across professional and non-professional users of the voice. SAJCD. Vol. 57, December 2010
Shipp, T., Hollien, H. (1969) Perception of the aging male voice. J Speech Hear Res 1969:12 (703-710)
Steinhauer, K., Klimek, M., (2017) The Estill Voice Model: Theory and Translation, Pennsylvania: Estill Voice International
Titze, I. R. (2000) Principles of Voice Production, 2nd Edition. Iowa City: National Center for Voice and Speech
Webster, J., Watson, R. T. (2002) Analyzing the Past to Prepare for the Future. MIS (Management Information Sciences) Quarterly. Vol. 26, no. 2 (June 2002)
Weiss, R. (1988) Women’s Skills Linked to Estrogen Levels. Science News, 1988
Williams, J. (2019) Teaching Singing to Children and Young Adults, Oxford: Compton Publishing
World Health Organisation https://www.who.int/news-room/fact-sheets/detail/ageing-and-health acessed 04/03/24
Zeigler, A., Hapner, E. (2013) The Behavioural Voice Lift. The ASHA Leader 18, no. 3