NATS Poster Paper Detailed Outline

The Larynx

  • In females, the larynx is subject to monthly hormonal fluctuations from puberty through menopause.

o   Larynx is a hormonal target organ.

  • There are hormone receptors in the vocal folds.
    • Receptors are a cell or group of cells that receive stimuli.

Overview of Steroid Hormones

  • Estrogen, progestogen, and androgen are steroid hormones responsible for the development and maturation of the primary and secondary sexual characteristics.
  • Steroid hormones are synthesized from cholesterol in the gonads and adrenal glands.
  • Steroid hormones diffuse easily across the cell membrane and bind to hormone receptors.  They are steroids that act as hormones and are grouped into five groups by the receptors they bind to.
  • Each of these hormones perform a designated action on specific receptors located in specific receptors located in target organs.
  • Sex hormone receptors are proteins that bind with specific hormones in the fluid component of a cell.

o   Estrogen

  • Estrogen is produced in the ovaries, and the corpus luteum; it is also produced in the adrenal glands and fat tissue.  As with androgen, estrogen is produced by both men and women, although the amount produced in men is extremely small.  There are three main types of estrogen:
    • Estrone (E1):

o   Produced by the adrenal gland and adipose (fat) tissue.

o   The primary estrogen of postmenopausal women.

  • Estradiol (E2):

o   The primary estrogen in women from menarche to menopause.

o   Produced by the adrenal glands and testes in men.

  • Estriol (E3):

o   The estrogen of pregnancy.

o   Produced in large amounts by the placenta.

  • Estrogen has a huge effect on the female body; it plays a role in sexual development and reproduction.
  • Benefits of estrogen are seen (and felt) throughout the body.
    • Sexual Organs
    • Brain
    • Liver
    • Muscle
    • Bones
  • Estrogen circulates though the bloodstream and binds onto the receptors of cells in targeted tissues and organs.
  • Estrogen
    • Prevents bone loss.
    • Works with calium and vitamin D to build bone.
    • Reduces cholesterol and triglyceride levels.
    • Reduces the risk of Alzheimer’s disease.
    • Reduces the risk of cardiovascular disease.
    • Increases capillary permeability.
    • Improves cognition.

o   Progesterone

  • Progesterone, which is a type of progestogen, is produced in the ovaries and adrenal glands.  During pregnancy, it is also produced in the placenta
  • Progesterone is also stored in adipose (fat) tissue.
  • Progesterone:
    • Stimulates the endometrium to secrete a protein during the luteal phase of the menstrual cycle, which nourishes the implanted egg.
    • Plays a role in libido.
    • Regulates the menstrual cycle.
    • Decreases and inhibits capillary permeability.

o   Traps extracellular fluid out of the capillaries.

o   Causes cellular congestion/edema.

  • High progesterone levels are responsible for the symptoms of PMS.
  • Acts as an anti-inflammatory agent.
  • Regulates the immune system.

o   Androgen

  • Androgen is considered a male hormone, but it is present in both males and females in differing amounts.
  • In women, the main function of androgen is to convert itself into estrogen.
  • The two main androgen are testosterone and androstenedione.
  • Influences female sexual behavior.
  • Produced in the testes of the male, the ovaries of the female, and the adrenal glands of both sexes.
  • Androgen:
    • Stimulates hair growth.
    • Regulates the function of many organs:

o   Reproductive organs.

o   Liver

o   Kidneys

  • Help maintain muscle and bone.
  • Prevents bone loss.
  • Regulates body functions before, during, and after menopause.
  • Androgen imbalance is one of the more common hormonal imbalances.
    • Excessive androgen (hyperandrogenism) can cause virilizing side effects:

o   Hirsutism (excessive hair growth).

o   Thinning hair.

o   Acne.

o   Skeletal muscle hypertrophy (excessive development).

o   Masculinizing effect on the voice.

Monthly Hormonal Cycle

  • The onset of the monthly hormonal cycle begins at puberty.
  • Puberty is when a child’s body develops and matures into adulthood.
  • Females typically begin puberty at age 10 or 11 and complete it by age 15-17.
  • Males enter puberty at age 12 or 13 and are finished by ages 16-18.
  • The age at which puberty occurs has dropped significantly since the 19th century; nutritional and environmental factors are thought to be among the factors.
  • Puberty is initiated by hormonal signals from the brain to the sexual organs: the ovaries in a female and the testes in a male.
  • The length of the monthly hormonal cycle (menstrual cycle) varies among women, ranging between 21 and 35 days.  28 days is considered the norm.
  • It is estimated that the release of one mature follicle every 28 days occurs approximately 400 times in a woman’s reproductive life.
  • The menstrual cycle can be divided into 5 phases:

o   Menstrual phase (days 1-5)

o   Follicular phase (days 6-12)

  • During this phase, the ovarian follicles mature and get ready to release an egg.
  • A rise in the follicle stimulating hormone (FSH) at the beginning of this phase stimulates a number of ovarian follicles.  Only one folicle containing the egg reaches maturity.
  • Also during the follicular phase, estradiol supresses production of the luteinizing hormone (LH).

o   Ovulatory phase (days 13-15)

  • Estrogen level is at its highest level.
  • Rising estrogen level stimulates a surge in LH, which matures the egg.
  • A mature egg is released.
    • Fertilized eggs will implant into the endometrium.
    • Unfertilized eggs dissolve.

o   Luteal phase (days 16-23)

  • During the luteal phase, FSH and LH the remains of the follicle create a new endocrine gland, the corpeus luteum.
    • The function of the corpus luteum is to secrete large amounts of progesterone.
    • As a result of the progesterone, the endometrium alters to prepare for the possible implantation of the ovum.

o   Premenstual phase (days 24-28)

  • Progesterone level at its highest level at the beginning of the phase.
  • Estrogen level at its lowest.
  • Premenstrual syndrome (PMS) occurs during this phase.
  • As both estrogen and progesterone lower, the menstrual phase starts.

Mentrual Chart

Premenstrual Syndrome (PMS)

  • PMS occurs as both estrogen and progesterone reach their lowest levels.
  • Physical symptoms include:

o   Weight gain

o   Irritability

o   Bloating

o   Fatigue

o   Anxiety

o   Headache

o   Insomnia/Hypersomnia

o   Mastalgia

  • Vocal symptoms include:

o   Hoarseness

o   Vocal fatigue

o   Edema/congestion of the vocal cords

o   Loss of power

o   Loss of high notes/decreased range.

  • In an article published in the Journal of Voice in 1989, Dr. Jean Abitbol found a similarity between laryngeal and cervical cytology smears.

o   Established a correlation between vocal changes during the menstrual cycle and physical changes during the menstrual cycle.

  • Abitbol referred to the monthly vocal changes as Premenstrual Vocal Syndrome (PMVS).

PMVS Chart

Oral Contraceptives (OCPs)

  • Overview of Contraception

o   Contraception existed in Mesopotamia and Ancient Egypt.

o   Condoms were used as far back as the 16th and 17th centuries.

o   The diaphragm was invented in the 19th century.

o   In the early 1900s, scientist Ludwig Haberlandt discovered that the monthly cycle was regulated by the brain and ovaries.

o   By the 1920s it was discovered the androgen, progesterone, and estrogen inhibited ovulation.

o   In 1938, a synthetic form of estrogen, ethinylestradiol, was created.

o   In the 1950s, a synthetic progesterone, progestin, was created.

o   Drug trials for the first oral contraceptive pills (OCPs) were conducted in Puerto Rico in 1956.

o   OC pills became available in the United States in 1960.

  • Oral Contraceptives

o   Early versions of OCPs contained high levels of estrogen and progestin.

  • High levels of estrogen linked to higher incidence of blood clots and stroke.
  • High levels of progestin caused virilization of the voice and hirsutism.

o   Progestin only pills were also developed.

o   There are several types of combination OCPs:

  • Monophasic
    • Have the same amount of estrogen and progestin in all the active pills.

o   Yaz

o   Ortho-Cyclen

o   Loestrin

  • Biphasic
    • Changes the levels of estrogen and progestin once during the menstrual cycle.

o   Kariva

o   Ortho-Novum 10/11

  • Triphasic
    • Changes the levels of estrogen and progestin every seven days for  the first 21 days of the menstrual cycle.

o   Cycless

o   Ortho-Novum 7/7/7

o   Orth-N0vum Tricyclen

  • Quadraphasic
    • Change the level of estrogen and progestin four times during the menstrual cycle.

o   Natavia

  • No evidence that any one type of phasic pill is more effective than another.
  • Triphasic and quadraphasic pills more closely and naturally compliment the fluctuating levels of the hormones found in the body.
  • Oral contraceptives maintain constant levels of of estrogen and progestin throughout the menstrual cycle.

o   Research has shown that women using low-dose OCs have healthier, more stable voices.

Pregnancy on Voices


  • Major changes occur during pregnancy, as the hormonal fluctuations cause bodily changes.

o   Concentrations of estrogen, progesterone, and tesosterone are higher than usual, affecting:

  • Larynx.
  • Bone tissue.
  • Muscles.
  • Mucosa.
  • Vocal issues that can occur during this pregnancy include:

o    Edema.

o   Reduced range.

o   Fatigue.

o   Change in timbre.

  • Pregnancy divided into three trimesters.

o   First trimester is a very important time.

  • Embryogenesis: cells form into the different body systems.
    • Features become visible.
  • Hormonal changes cause the swelling of mucous membranes.
  • Morning sickness.
  • Water retention.
  • Medication ingestion must be limited.

o   Second trimester

  • Morning sickness usually disappears.
  • Singing is easier during this time.
  • Breath support improves.

o   Third trimester

  • Breath support becomes problematic due to the increasing size of the uterus.
    • Clavicular breathing.
    • Lateral breath expansion.
  • Abdominal distention hinders abdominal muscles.
  • Reflux can occur during this time.
    • Can cause hoarseness.

Vocal Issues Menopause


  • Menopause is the ending of the monthly menstrual cycle and fertility.

o   Perimenopause is the transitional period in which the ovaries gradually stop producing eggs, estrogen and progesterone.

  • The primary cause is the loss of follicles in the ovaries which results in lowered estrogen levels.
  • Progesterone secretions stop.
  • Another cause is surgical procedures, such as chemotherapy, hormone therapy for breast cancer, or ovary removal surgery, which cause a drop in estrogen levels.
  • During perimenopause, menstrual periods become less frequent or irregular and eventually stop.

o   After a woman has not menstruated for a year, menopause is complete, and she is considered to be postmenopausal.

o   The age range of menopause is between the ages 40-58.

  • Smoking can lower the age of the onset of menopause.

o   Physical symptoms vary from woman to woman and can last for years, and can include:

  • Insomnia.
  • Hot flashes.
  • Night sweats.
  • Mood swings.
  • Genital atrophy.
  • Osteoporosis.
  • Increased risk of cardiovascular disease.
  • Headaches.
  • Decreased libido.

o   Vocal symptoms include:

  • Laryngeal mucosal changes.
  • Lowering of vocal intensity.
  • Decreased fundamental frequency.
  • Reduced range.
  • Reduced flexibility.
  • Loss of high notes.
  • Loss of upper formants in the upper range.
  • Loss of stamina.
  • Problems with onset.

o   As the estrogen and progesterone levels decrease, androgen plays a more important role in a woman’s body.

  • Androgen causes muscular and mucosal atrophy.
  • Reduced hydration of the vocal folds, causing:
    • Fatigue.
    • Dysphonia.

o   Lack of estrogen causes a breakdown of connective tissues.

  • Vocal folds are made up largely of connective tissue.

o   Estrogen is produced in the fat cells of postmenopausal women.

o   In addition to the menopause, women also have to contend with the age-related changes to the voice:

  • Degeneration of muscle tissue.
  • Vocal fold thickening.
  • Ossification of many cartilages in the larynx.
  • Stiffening of the thorax.
  • Reduction of vital capacity.
  • Increasing residual volume.

Treatment of Symptons


  • Conducted in January 2014 on

o   The 249 participants were recruited through social media.

  • Survey consisted of 32 questions, covering:

o   Background information

  • Age
    • 22.50% between the ages of 18 and 25
    • 31.25% between the ages of 25 and 35
    • 15.83% between the ages of 35 and 45
    • 22.08% between the ages of 45 and 55
    • 7.08% between the ages of 55 and 65
    • 1.25% over the age of 65
  • Voice Type
    • 65.69% were sopranos
    • 22.62% were mezzo-sopranos
    • 3.77% were altos
    • 2.93% were contraltos
  • 72.34% said singing was a profession; 27.66% said it was an avocation.
  • Years of study
    • 2.10%: No years of study
    • 1.26%: Less than a year of study
    • 4.62%: 1-2 years of study
    • 15.55%: 3-5 years of study
    • 26.89%: 5-10 years of study
    • 49.58%: More than 10 years of study

o   PMS

  • 74.47% of women suffered from PMS

o   PMVS

  • 62.34% of women suffered from PMVS
    • 28.37% said their symptoms were slight
    • 55.32% said their symptoms were moderate
    • 13.48% said their symptoms were severe
    • 2.84% said their symptoms were debilitating
  • 74.47% said their symptoms caused them to deviate from their practice schedules

o   OCPs

  • Of the 71.75% women that used oral contraceptive pills, 41.25% used them for reasons other than contraception.

o   Pregnancy

  • Of the women who had given birth, 73.33% said their voice was affected

o   Menopause

  • 21.82% of the women surveyed said they had gone through menopause.
    • 58.70% said it had affected their voices.

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