In response to a recent specific question about menstrual cramps, I decided to write a more general article dealing with several issues that arise during menses. This regular (hopefully!) hormonal cycle, in its various physical manifestations, is the female singer’s constant companion from menarche to menopause, years which coincidentally also represent much of her performing years. Some women sail through month to month with minimal vocal difficulty—but others are severely limited, particularly during the days before the onset of their periods, and then continuing into the first few days of actual menstruation.
Opera lore lovingly tells of olden times in European opera houses when menstruating singers were contractually excused for “modesty days.” To the best of my knowledge, this is no longer the rule, nor is it practical. In those halcyon days, each opera house had its own troupe of singers, a little family that was under contract and salaried, and performed a season of operas using mostly the same cast singing the different roles. Guests were uncommon.
This is no longer the case. Today’s typical singer is a guest performer, flown in for a few performances, then heading off to another theater. If a singer’s run is three or four shows over a couple of weeks, and those weeks come at a bad time, she either has to cancel the engagement, or deal with her hormones. If you don’t sing, you don’t get paid—and the routine loss of 25 percent of a singer’s performing time is usually not an option.
Several problems associated with menstruation can impair your singing ability. These include fluid retention, abdominal cramps, and an increased tendency to hemorrhage, not to speak of the emotional lability of PMS! The causes of these ailments, their effect on singing, and suggested remedies are discussed below.
In the week before menstruation, women have a tendency to retain fluids, due to a relative increase of progesterone in the body. The accumulation of fluid involves many of the soft tissues of the body, and can make tissues less flexible, more unwieldy. The larynx becomes less supple, and the vocal folds feel thick. The voice can feel husky; the high notes, particularly soft ones, become more effortful, even impossible. The quality of the voice can coarsen. Supporting and sustaining the voice can become more difficult, since fluid retention also affects the abdomen.
The abdominal cramps that begin days before menses and extend into the time of menstruation—caused by the contractions of the smooth muscle of the uterus that result in the separation and discharge of the endometrial lining—can be mild or incapacitating. These cramps, which typically ease off in the later part of the period, can impair a singer’s ability to support the voice.
The process of endometrial shedding is accompanied by a generally increased tendency to bleed. Many women find that they have more nosebleeds (charmingly referred to in older books as “vicarious menstruation”) or that their gums bleed more easily when they brush their teeth. For singers who have a history of vocal fold hemorrhage, these may be precarious days.
What with the miscellaneous ills of emotional lability, migraines, and other assorted aches and pains, it’s no wonder some singers almost look forward to the blessed hormonal silence of menopause!
And now, some suggested remedies. Again, let me issue my usual disclaimer: as a laryngologist I can only comment on these issues generally, and as they pertain to the voice. So please consult your friendly local gynecologist for more specific advice!
Regarding premenstrual fluid retention, try to restrict your sodium intake. Paradoxically, some women crave salt at this time, but keep in mind that the sodium ion holds water in the body. So try to limit salt intake. You should also consider a mild herbal diuretic, such as a diuretic tea. In cases of vocally incapacitating fluid retention, ask your doctor about the possibility of taking prescription diuretics for a few days. Make sure, however that there are no contraindications, such as low blood pressure.
You can manage abdominal cramps in several ways. Anti-spasm medications can help uterine cramps, as well as intestinal cramps and diarrhea. These medications are often somewhat drying, however. What about pain relief? Doctors usually advise singers to avoid all anti-inflammatories, for fear of vocal hemorrhage. Contrary to prevailing opinion, I believe that—in the absence of a history of laryngeal hemorrhage or abnormal blood vessels on your vocal folds—there is no reason not to take an occasional Aleve or other analgesic medication. Does this increase your chance of vocal fold hemorrhage? In theory, possibly, but in reality, probably not.
The application of heat to the abdomen, either a hot bath or heating pads, increases blood flow in the area and hastens the resolution of cramps. Acupuncture (with or without the application of heat) can also be quite helpful in relieving abdominal cramps. Chinese herbs such as dang qui (Radix angelicae sinensis) can help with both cramps and PMS in general. Obviously, the last two suggestions need to be pursued with a qualified non-Western medical practitioner.
Going on the pill can also reduce painful periods, an option you should discuss with your gynecologist. Oral contraceptives can darken the voice, but taking a lower-dose oral contraceptive is generally a safe option, especially for lower female voices.
I have already mentioned the issue of hemorrhage. Although the chance of vocal fold hemorrhage in singers with healthy larynges is low, I would recommend avoiding medications, herbs or dietary supplements that clearly promote hemorrhage. Aspirin or other medications taken to thin the blood should be avoided, unless you need to take them for medical reasons. As mentioned above, other non-steroidal anti-inflammatories (such as ibuprofen), taken occasionally and in the absence of other potentially precipitating factors, should not significantly increase the chance of laryngeal bleeding.
And now, the mood swings. First, be aware that your pre-menstrual emotions are hormonal, and self-limiting. Minimizing fluid retention (see above) can be helpful. Also, you can consider any mild mood-altering medications that can help you though this time. Again, acupuncture can be very helpful in harmonizing the spirit, and carries the additional benefit of simplicity and no side effects.
What if you have done all you can, and despite your best efforts are stuck with an important performance smack in the middle of your period? It’s possible to delay the period with hormones, by continuing your oral contraceptives. A recently introduced oral contraceptive regimen (“Seasonale”) allows you to take pills for three months at a time, and have only four periods a year. While I can’t comment on the health implications of repeatedly delaying (or even completely stopping) your periods with medication, I have occasionally advised singers to do so, and with good vocal results.
Perhaps most importantly, lower your vocal expectations during your problem days. Don’t push for effortless high notes, long phrases, and a great expressive variety when your vocal folds are swollen and your clothes are tight.
As with most health issues, the above suggestions are general. It is up to each singer to find the right combination of remedies for her particular situation.
