Dear Dr. Jahn: I have a quick question about birth control and its effects on the voice. I’ve heard anecdotal evidence from singer friends about birth control pills affecting the voice in terms of some loss of range and flexibility. Is there scientific evidence that backs this up? What is the safest form of birth control for a singer?
AFJ: We actually covered this topic a couple of years ago and ran a survey canvassing readers about their own experiences. In brief, we believe that BC pills that contain synthetic progestins may darken some voices, particularly the higher and lighter soprano (like soubrette) voices. This is because synthetic progestins metabolize into a testosterone analog (androgenic), which can masculinize the voice. We presented this paper at the Voice Foundation meeting several years ago.
How individuals react to specific oral contraceptives is unfortunately idiosyncratic and somewhat unpredictable. If you have a high and light soprano voice and plan to take BC pills for birth control (rather than to regulate your periods) you may want to look at alternative methods of contraception. In any case, discuss with your gynecologist what is in the BC pill that she/he plans to prescribe. I cannot refer you to a specific authoritative article on the topic, but am sharing with you what our current thinking is. I’m sure you will find relevant articles by googling the appropriate key words.
—Dr. Jahn
Dear Dr. Jahn: Can you please explain the effects of thyroid diseases on vocal production?
AFJ: The thyroid gland secretes two major hormones which regulate the body’s metabolism. In brief, benign thyroid disease causes either excessive or insufficient secretion of these hormones, which is called either hyperthyroidism or hypothryroidism.
Patients who are hyperthryroid are in a hypermetabolic state—they are hungry, always too warm, sweat a lot, lose weight, have abnormal periods, and their heart is also in overdrive. From the vocal point of view, the most significant problem is a vocal tremor. This is not a vibrato, but a lack of muscle control that cannot be technically controlled. The treatment is to diagnose the hyperthyroidism and then to suppress the excess secretion—either with medication that reduces the hormones or by ablating the thyroid tissue with radioisotopes and then replacing it with oral thyroid hormones.
More common, especially in middle-aged women, is hypothyroidism. This can be quite subtle in presentation and often begins with fatigue, a sensation of feeling cold all the time, and weight gain. Other symptoms are constipation, changes in the menses, and hair loss. The vocal issues here are a huskier voice and one that is unwieldy and loses flexibility and color. Some women present with chronic hoarseness. As you see, these are all pretty nonspecific symptoms—who isn’t tired all the time? But hypothyroidism should always be suspected, because it is easily corrected with oral medication.
Now, whether you are hyper- or hypothyroid, once the condition has been identified and your hormone levels restored to the correct (euthyroid) level, your voice should be fine. Neither hyper- nor hypothyroidism should cause any irreversible damage to your larynx or your voice.
—Dr. Jahn
Dear Dr. Jahn: More and more singers seem to be relying on cortisone nasal sprays and injections to mask illness symptoms in order to avoid canceling performances when ill with sore throats, sinusitis, or the flu.
Could you address the long- and short-term side effects of the use of these medications and explain the dangers of relying on these drugs for singing? I would like to make my colleagues more aware of the negative aspects of this use that exceeds the loss of an evening’s paycheck, as well as inform the beginning singers who are easily encouraged to depend on medicine to replace technique and discipline.
AFJ: First, I share your concern for singers who deal with chronic problems by simply relying on cortisone from one concert to another. This is really a topic for an entire column, because it touches so many areas—the psychological aspects of denial, the emotional aspects of needing to perform, the professional pride of being reliable, and the financial necessity of not canceling. I am particularly concerned when a singer travels and gets shots from doctors in different cities, just to get through the next show. That shot is usually just another form of cortisone, and the treatment shows a lack of foresight on the part of both physician and patient.
With regard to long- and short-term effects of steroids, let me discuss a few items. Clearly, cortisone is a good and quick fix for inflammation, whether from an infection, allergy, or the trauma of excessive voice use. And there are definitely some performances that are potentially career making, which you simply need to get through. The problem comes when a singer relies on cortisone to get through most performances, neglecting the true nature of the problem (whether infection, allergy, or vocal trauma) and failing to address that.
In general, bacterial infections should not be treated with cortisone—it suppresses normal immune function which, through inflammation, helps your body to get rid of the infection. Viral infections, while not normally requiring specific antiviral medication, should be allowed to run their course, allowing the body’s normal defenses to get rid of the symptoms. And again, with allergies, the ideal treatment is to identify what you are allergic to and then either eliminate the allergens from your environment or get immunotherapy (injections) to reduce their effect. And, finally, the treatment for vocal trauma is vocal rest and then a rethinking of what you are doing, either technically or by way of repertoire or performance schedule, that has made you hoarse. Treating the cause is always better than just ameliorating the symptoms.
Having said all of that, the short-term effects of cortisone can be beneficial at times for the voice. While some lower male voices experience a loss of high notes (a “ceiling effect”) and have also complained that the voice in general “sounds different,” at least it’s there, and you may get through your performance. This comes at the cost of increased appetite, elevated blood sugar, and a temporary suppression of immunity. Inhalants have less impact on the body, and act more locally. Steroid inhalers, usually used for asthma, can have a “quick-fix” effect if you are hoarse from vocal fold edema, if you are coughing from tracheitis, or are wheezing.
The long-term effect of steroids is more potentially hazardous. Repeated and regular steroid injections suppress your adrenal glands, leaving you immunologically weakened. It can cause diabetes, osteoporosis, and even necrosis of the femur (hip). It is associated with weight gain and skin changes. There are also psychological changes. Unfortunately there are conditions (like severe arthritis or autoimmune diseases) that may require this treatment—but if you don’t need it, why risk these things?
Steroid inhalers, while less systemically toxic, over time can cause yeast infection of the throat and larynx and may actually weaken the voice due to atrophy of the vocal muscles and weakening their contraction (steroid-induced myopathy). The result is a hoarseness that may be long term and will definitely not be cured by yet another cortisone injection.
—Dr. Jahn
