Hormone Replacement Therapy
Dear Dr. Jahn,
I was wondering if you could provide any advice on considerations and recommendations for hormone replacement therapy. I am planning to go on some kind of HRT, but I have no idea if there are any that are better for singers than others, etc. I feel that many women singers will be interested in this. Thanks for any advice or information to which you can direct me.
From the vocal point of view, HRT is definitely beneficial: it keeps the tissues moist, flexible and young. The real question pertains to other concerns with HRT, such as heart attacks and strokes. If there is no significant history of these conditions in your family, you are probably at low risk, and, after discussion with your gynecologist, may decide to take HRT after menopause.
As to what is best, this is not clear. Some advocate natural sources of estrogen, such as soy, black cohosh, and other herbal sources. This sounds more holistic than synthetic hormones—but there have been no studies to show that the potential side effects are any less than with conventional hormone replacement. Either way, estrogen gets to your tissues, and is helpful for your voice. Avoid synthetic testosterone, since it can darken the voice—you would of course not normally take this. Have a detailed discussion with your gynecologist, though.
—Dr. Jahn
Sleep Apnea
Dear Dr. Jahn,
My ENT has suggested that he perform a UPPP [Uvulopalatopharyngoplasty] on me in order to treat sleep apnea. (He uses the new technique using ultrasound). I’m a serious amateur singer, and am a bit concerned about what effect this procedure might have on my voice. My ENT showed me, in a mirror, that my throat opening is quite small (and I have an unusually large uvula).
Can you comment as to whether a UPPP would help, hurt, or be neutral with respect to my singing and speaking voice? Also, can you say how effective it might be in treating the sleep apnea?
A UPPP (or versions of it) reduces the length and flaccidity of the soft palate, and is often dramatically helpful in eliminating snoring. Sleep apnea can occur with snoring, but the two are not identical: Some people snore loudly with no sleep apnea, while others have sleep apnea but do not snore.
Regarding the effect on your voice, there is always some worry that the palate may not work as well as it did before the procedure, although in most cases it isn’t a problem. I have done this surgery on one singer, and it turned out well, but I wouldn’t normally jump to palate surgery in singers.
Have you discussed using a CPAP [Continuous Positive Airway Pressure] machine rather than surgery? It might be a good option. If you cannot use the CPAP machine, and there are really no other options (such as significant sleep apnea with severe oxygen desaturation), I would suggest that the procedure be done conservatively (less tissue removal). I have had no personal experience with the ultrasound device for this condition.
—Dr. Jahn
Abnormal Vocal Fatigue
Dear Dr. Jahn,
I would very much appreciate your professional opinion and guidance in reference to abnormal vocal fatigue, which I have been experiencing the past four months. I am presently attempting to prepare for a recital. Over the past few months, I have not been able to increase my vocal stamina past much more than a half hour. I have analyzed, and analyzed, and then re-analyzed the situation to try to find some explanation for this lack of stamina.
Let me try to briefly inform you of some “things” that may be affecting my stamina. First, I took this problem directly to my voice teacher to assess my technique and look for the “moth holes” that may have appeared due to a lapse in consistent vocal training. She has found no major technique flaws … and I am aggressively pursuing a more consistent lesson schedule.
I performed a “mezzo” theater role a few months ago, for a short run with a community theater—which I know could have caused some fatigue, seeing as I am a lyric coloratura.
Next, I was wondering if this fatigue could be due to hormones. I have also experienced some major physical trauma over the past several years, but only began to experience the fatigue recently.
I assume it could be a mix of many things causing this current predicament. However, I have become quite uneasy as time goes by and my stamina does not improve. I have been considering going to see an ENT, but I have a few questions before I do so.
Would it be a waste of my time and money to see a doctor who is not well versed in the workings of the “athletic voice?” Would you recommend I set up an appointment with the intent of having my vocal folds scoped? Do you feel I should continue with voice lessons for a set time before pressing forward with a medical evaluation?
Many heartfelt thanks from one very passionate musician who is desperately seeking to solve this personal dilemma!
First, a couple of questions: Are you generally fatigued, or just vocally? Are you under physical or psychological stress? Do you have pain when you sing, or just fatigue? Might you be anemic (not enough iron in the diet, heavy periods)?
I would get a good general checkup first to rule out underlying medical conditions, such as low thyroid, low blood count, chronic infection or inflammation, or any possible neuromuscular condition (such as myasthenia). Then, look at whether anything has changed in your voice use, speaking or singing, recreational or professional, such as new technique, new repertoire, or a new teacher. If all this is fine, you should get scoped and examined.
—Dr. Jahn
Vocal Dry Spot
Dear Dr. Jahn:
I read your column regularly in Classical Singer and thought I’d seek your advice about a rather unusual problem that a new student of mine has had for a few years. This man is in his mid-fifties and although not a professional singer, has studied voice and performed quite a bit in the past. A few years ago he had to stop singing for a while. At one point, he developed what felt to him like a dry spot in his throat. Whenever this dry spot occurred, it caused him to cough so much that he couldn’t continue singing. He also found it difficult to swallow at times.
A couple of years ago, he went to an ENT at Stanford who told him that he had a polyp on his vocal cords and gave him an inhaler to use. A few weeks later my student went back and was seen by a different doctor—one who was studying acid-reflux. He was told that the polyp was gone but that the dry spot was caused by acid reflux. My student received acid reflux medicine to take.
Needless to say, neither of these diagnoses cured the problem, hence the need for my student to stop singing for a while. At his lesson the other day (his first with me), he approached things lightly and after an hour of singing, he was fine. He’s concerned with the problem coming back and I was wondering if you might have any ideas as to what the problem might be and how to deal with it.
Both of the diagnoses were good starting points, but obviously the failure to respond to treatment should suggest other causes. I’m assuming that your student took his anti-reflux meds in adequate doses and for a long enough period of time. In the absence of any visible lesion, I would suggest a trial of Singulaire to address a possible allergy, atypical asthma or reactive upper airway. Make sure he is adequately hydrated (8-10 glasses of water a day). He may also wish to try Guaifenesin to moisturize the area. Good luck!
—Dr. Jahn
