Testosterone replacement can slow down sarcopenia, making it less inevitable, “if” mixed with a great workout routine.
Testosterone replacement (TR) can be mood, brain and immune boosting, but it may also have some shadow sides.
I remember when I worked with an internist in OK. He had a professional singer start on bioidentical hormone replacement (BHRT). It included TR. He gave it as injections.
Her vocal range changed.
Not for the better.
Her vocality did not improve even when going off the TR.
This doctor got sued.
The patient won.
When you go onto BHRT you need to have a written disclaimer that any patient signs for many things. But one of them is warning about possible irreversible changes to “vocal tonality”. Mostly from TR.
A collaborative study dove into this.
Who did this study?
1Sean Parker Institute for the Voice, Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medical College, New York, New York. Electronic address: kac9235@med.cornell.edu.
2The University of Texas Health Science Center, Department of Otolaryngology, San Antonio, Texas.
3Sean Parker Institute for the Voice, Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medical College, New York, New York.
4The University of Texas at San Antonio, Department of Music, San Antonio, Texas.
Their abstract or summary says:
Abstract
Objectives: To describe voice changes as a result of the off-label use of androgen supplementation in women.
Methods: A multi-institutional retrospective consecutive case series identified women taking androgen supplementation who presented to voice clinics at two institutions with a chief complaint of voice change between 2014 and 2019.
Results: Nine women presented with voice change after initiation of androgen hormone supplementation. The mean age was 55 and three patients were performers. All patients underwent hormone therapy with testosterone supplementation, most commonly subcutaneous testosterone pellets.
Six patients (67%) were being treated for menopause symptoms, one patient for decreased libido, one patient for breast cancer, and one patient who desired additional muscle gain.
Time of symptom onset after hormone therapy initiation was highly variable, ranging from 0 to 48 months with a mean of 15 months.
Mean Voice Handicap Index-10 was 21, mean fundamental frequency at comfortable speaking level was 155 Hz and mean semitone pitch range was 22 semitones. Two patients had markedly elevated serum total testosterone levels. Hormone therapy discontinuation and voice therapy were recommended in six (67%) patients each. Five patients returned for follow-up after treatment and noted some subjective benefit.
Conclusions:
Female patients treated with androgen supplementation may experience “unintended voice changes”, most prominently “reduction” in fundamental “frequency”.
Although some benefit may be obtained from voice therapy and cessation of hormone therapy, voice changes may be “permanent”.
Caution should be exercised when prescribing these medications to women.
Some women who are not singers may like these possible vocal changes. A deeper, sexier voice. Not all women get vocal changes. Many men maintain more manly tones.
Women on BHRT often maintain their :younger voices” rather than developing “older sounding voices” as is typical in most humans.
Aging vocal changes are often slowed down by individualized BHRT.
In other words, BHRT can protect aging of the vocal chords.
But if testosterone is added to the mix, then the “vocality range” of professional singers may be adversely effected.
You must let your patients know this. Give them informed choice. Ahead of time.
There’s more.
Singing is a highly developed physical and cultural performance.
Many professionals depend on good vocal health in their professions — singers, lawyers, teachers, actors, announcers, kindergarten teachers.
I speak a lot. Often to large audiences. For many hours.
I have to keep up my “vocal chops”.
But professionals sometimes have persistent hoarseness, vocal cord nodules, or cysts.
What can voice professionals do to protect their voices?
What if a voice can no longer meet the demands of someone’s profession?
The voice must fit the requirements of the job. It's not just about volume but also about specific sound characteristics that can carry the voice far into the room.
Projection matters.
Voice Function Therapy’s 3 Ingredients
Breathing provides the air needed to flow through the vocal cords.
Then there are the vibrating vocal cords themselves, which produce sound when set in vibration by the airflow. Vocal cords need to be healthy to vibrate freely. Exercise that enhances breathing helps this.
And there's also the resonance system of the mouth and throat, which shapes the sound. Your have sex steroid receptors all throughout these tissues, like estrogen and testosterone.
You can work with a vocal intensive professional.
There are Institutes like the Institute for the Voice, Department of Otolaryngology, at Weill Cornell Medical College.
All my kayaking and gym time, where I breathe deeply often, exercises my breath and vocal tissues.
I also feel the progesterone signals help boost lung capacity and projection, for being able to talk loudly, and project. For long periods of time.
Estrogen receptors also line vocal chords.
TR has not affected me an adverse manner since I am not a singer.
When I get my pedicure, the professional often comments that she can hear my voice. She mostly can’t hear the voices of many of her elderly patients, when they are talking and she is sitting at their feet. They don’t have lung and vocal health to be able to project down toward their feet.
Projection takes breath, stamina. And hormone health.
What else do professionals do to keep their voices fit?
They warm up their voices before a performance.
For example, they perform selected vocal exercises that facilitate agility and flexibility of the voice.
They do humming exercises that activate the "placement" of the voice: that is, the specific resonance settings.
They apply mental focus.
Resting the voice is essential. As the voice needs breaks, too.
Moral of this hormone vocal cord connection:
Keep in mind if you offer testosterone therapy to your aging patients, that “signed informed consent” helps all involved understand possible outcomes.
Not everyone wants to sound like Marlene Dietrich.
Of course, rarely does TR make ladies sound like that.
But some vocal changes may occur. Most of them are for the better.
But in some singers, this may not be the case.
Knowledge is power.
Dr. B.
References:
Voice Change Following Testosterone Supplementation in Women: A Multi-Institutional Case Series. J Voice. 2021 Nov;35(6):936.e1-936.e7.
How Can Singers Keep Their Voices Healthy? - Medscape - Feb 27, 2024.
Thank you Dr. Berkson, very interesting & informative article👍 as you saying knowledge is power!
I have always wondered how hormones affect the voice. I am a music teacher, (19 years now) I have often asked the professors in professional development sessions about hormones and the voice. No one has ever been aware of these things. I have always noticed during ovulation my voice quality is outstanding, and during other times of the cycle its not the same. I obviously can always sing on pitch and don't have problems with intonation, but the quality and clarity of the voice does changing throughout the month as my hormones cycle. I have always assumed that as i get older and menopause comes my way.... my voice quality will go down hill from a lack of hormones, but as science continues I have hopes this will not happen. Thank you for your dedicated and continued research regarding health and hormones. May God bless you for making us "non-physicians" aware of these facts... it gives us back some power.