For many years, indeed well before the 20th century, the effect of the menstrual cycle on women’s lives has been a subject for research and speculation. Pre-menstrual syndrome has become more recently acknowledged as a cause for concern with regard to women’s health both physiologically and psychologically. Katharina Dalton (1964) lists thirty-eight symptoms under specific physical area headings which range from irritability to glaucoma. The variance in degree of severity is extreme, from a total absence of symptoms to such overwhelming psychological disturbance that psychosis has been documented.
It is not then surprising that many researchers have dedicated considerable time and effort to the discovery of the effects of fluctuation in hormonal activity during the menstrual cycle. In 1962 Smith-Frable documented case studies of three women who were professional voice users (such as actors, telephonists, teachers). These studies were based on the women’s own pre menstrual symptom experience in relation to the reliability and tonal quality of their voices. Since these studies, there seems to be a definite emphasis on scientifically based investigations with most of the research directed at otolaryngologists, speech pathologists and the symptoms of pre-menstrual syndrome that specifically target the larynx.
In my experience, as a singer, it is near impossible to isolate the production of a professional singing voice to merely the workings of the larynx and immediate musculature. One cannot begin to fully understand the extent of effects without taking into consideration all of the physical ramifications, as well as the psyche and even the cultural context of menstruation. My research question thus evolved: in what ways does the menstrual cycle affect the use of the trained singing voice? The research accommodates physiological, psychological and cultural dimensions in such a way that the document itself may be useful to singers, teachers of singing, and indeed the broader community of professional voice users. There is an undoubted need for a study that is accessible to professional singers. After extensive reading on the subject, I have found that a significant gap occurs in this area. The language specific to the study of this subject is difficult to understand, to say the least, thus important information that would be of great help to a professional singer, and the further understanding of her instrument, serves only to widen the schism that already exists between science and art. As yet, to my knowledge, no one has approached this subject with the intent of providing information for the “average” female professional singer. I use the word “average” loosely as an acknowledgment of those singers who, like myself, have waded through the existing information sorely lamenting the absence of a degree in science. It is for these reasons that the need for this study is long overdue.
For the purposes of this publication I will highlight three areas of the research:
first— a brief look at the documented symptoms related to hormonal fluctuation,
second—a short section on the psyche of the singer, and finally, an extract from the larger research paper (from which this article derives) highlighting some natural therapies that were recommended by naturopath Ruth Williams (Dip. Appl. Sci., Naturopathy), to help overcome some of the more common symptoms of hormonal fluctuation for the singer. I have also provided a bibliography for those interested in further reading.
Physiological Symptoms of the Menstrual Cycle and PMS Affecting the Voice
Hoarseness is the most highly reported symptom of PMS in singers. It has been stated in many studies that the larynx is a hormonal target organ and that the dramatic drop in estrogen during the latter part of the luteal phase seems to be a pivot point, at which time the metabolic state of the laryngeal cells is altered and a subsequent change in vocal quality can arise.
During this time the “ground substance” of the vocal folds increases in its capacity to retain fluid, and this, in turn, manifests as an engorgement of the fold tissues. Any increase in the size of the folds will result in a lowering of pitch, as in the observation that the only difference between the voice of a woman and that of a man is the overall mass of the folds. (This theory can be applied to other instruments; for example the thicker the string on a violin, the lower the pitch)
Hoarseness would also seem to be a result of combined symptoms such as fluid retention, lethargy, cramping, and constipation, which may contribute to the lack of breath support needed for successful fold adduction. Most studies isolate hoarseness, and refer to “frequency perturbation” during the pre menstrual period as a symptom solely related to the larynx, without noting that for a singer it is impossible to dislocate elements of her instrument in the production of tonal quality.
Fluid retention, or edema, is a symptom of PMS that not only creates problems for the vocal folds, but also for the musculature directly related to breath support. Again the mid-luteal drop in estrogen creates a trigger that increases tissue permeability, resulting in excess fluid buildup. As all tissue can be subject to this process, it would seem logical that the effectiveness of the musculature of the lower abdominal and inter-costal regions, so important to the support of the voice, may also be hindered during this time.
Submucosal hemorrhage of the vocal folds has been reported as a common, and extremely severe, symptom of PMS. During the luteal phase, thyroid gland activity is higher, demanding a higher blood supply. The arteries supplying blood to the thyroid share a common vascular source with the larynx, thus both are affected by the increase. During this time of heightened blood/tissue ratio, (combined with possible edema), the vocal folds’ susceptibility to hemorrhage is heightened.
Research into the effects of ovarian hormones on the singing voice has lead to revelations about the levels of testosterone in the dysfunctional voice. Blood tests taken in a study of problematic voices (that is, for example, students exhibiting vocal problems such as breathiness, weakness, and lack of flexibility) revealed that testosterone levels in these subjects were higher than normal. This, in turn, supported a correlation between irregularities in the cycle itself and problems with singing. It is interesting to note, too, that many of the symptoms that had previously been documented as being part of PMS for a singer with a normal cycle, may present similar situations for the singer experiencing problems with irregularity of the cycle itself.
Other less medically serious symptoms such as constipation and diarrhea have been reported, creating vocal unreliability and frustration in the professional singer. Loss of upper range is of major concern, along with uncertainty of pitch. Both of these symptoms were attributed to fluid retention.
Much research has attempted to expose the reasons that hoarseness occurs in relation to hormonal fluctuation, and a large portion of this work is currently, and has been undertaken in the area of acoustic evaluation. By studying a single phase of fold vibration, or indeed the difference between successive cycles of vibration, researchers have been able to report variations that occur during specific periods of the menstrual cycle, revealing the slightest abnormalities in voice production. Evaluating such acoustical anomalies in isolation can yield results that are fragmented and lacking in context.
Current studies divide into two main categories—those of self-reporting and/or questionnaire response, and those of a clinical scientifically based nature, whereby subjects’ laryngeal function is monitored electronically. The problem with the latter kind of research is that the processes of singing are dealt with in isolation; that is, these studies create an “artificial environment” disregarding the fact that for a singer, the entire body is the instrument. Sataloff supports this view:
“The anatomy of a singer is not limited to the region between the trachea and hyoid bone. Practically, all body systems affect the voice. The larynx receives the greatest attention because it is the most sensitive and expressive component of the vocal mechanism, but anatomic interaction throughout the patient’s body must be considered in treating the patient’s voice.” (1987:92)
This statement, by a scientist, but one who specializes in the singing voice, clearly indicates a higher understanding of the unification of the instrument as a whole. Such an attitude is crucial for a fuller knowledge of the physiological aspects discussed thus far.
Menstruation, PMS, Singer and Psyche
It is a well-known fact amongst voice specialists, and singers themselves (and indeed all performing artists), that mental state greatly affects performance. The study by Davis and Davis in their article The Effects of Premenstrual Syndrome (PMS) on the Female Singer begins…“I always thought that PMS meant Perfectly Miserable Singer.” (1993:337) For many women the psychological effects of PMS are the most difficult to overcome. Symptoms that effect the emotions and intellect can leave the singer feeling vulnerable, defeated, and overwhelmed. Davis and Davis list what they refer to as the “wide array of neurological, psychological and interpersonal symptoms of PMS” as including, anxiety, irritability, depression, and then…“morbid or pessimistic thoughts, paranoia, loneliness, clumsiness, difficulty concentrating, dizziness, fainting, accident-prone behavior, memory lapses, tension or migraine headaches, and seizure disorders.”(1993:341)
Cognitive psychologists note the extremely complex series of processes that make up a performance, and revere the “expert” musician’s ability to simultaneously sustain these processes. A musicians’ ability to reach a point of synchronization of the skills needed to perform successfully relies heavily on their capability to create a cognitive store of “automatic” reflexes. This store of general knowledge then creates a framework for extension, allowing new material to be learned and mastered, broadening the “expert’s” base further.
A fluctuation in ovarian hormone levels may prevent the female singing performer from relying on the “automatic” aspect of her instrument, thus adversely affecting the creative cognitive processes that she may also have come to consider an “automatic” and integral part of her ability. The most devastating effects of PMS on the female singer may well be in relation to a fluctuation in perception of self. As mentioned earlier, paranoia and hypersensitivity, self-doubt and depression, can play havoc with the psyche of the performer. It is thought that cyclic emotional problems, related to PMS, may, for many young students, have been a deterrent in their striving for a career in singing. The frustration of being capable and secure some of the time, then unable to produce the same level of competence at other times, could inspire even the most motivated and dedicated student to give up.
Davis and Davis hypothesize the idea that the singer suffering with PMS may well close herself off, subconsciously, from new ideas and concepts because of her feelings of depression, defeat and distraction. This, in turn, may cause problems for those with whom the singer lives and works. The resultant frustration can also affect other professionals in contact with the singer: the voice teacher, accompanist, and coach, who have heard potential and then witness the same voice unable to attain the desired and/or expected outcome.
One of the most challenging aspects to overcome for the professional singer suffering with hormonal fluctuations is related to reputation. Davis and Davis provide conclusive evidence that emerged when the researchers looked back over time and correlated the behavioral misdemeanors, and self-professed unreliability, of some of the most famous “divas” of our time as characteristics retrospectively attributed to PMS.
Maria Callas, for example, may have suffered with PMS. After examination of performance dates, diary entries, interviewing friends, and listening to recordings, a cyclic pattern of emotional instability emerged. Emotional outbursts, volatility, depression, low self-esteem, binge eating, weight shifts, health and vocal problems were all attributed to symptoms of PMS.
In an interview with Joan Sutherland in 1970, Life magazine printed a rare and candid comment by the singer, in relation to her menstrual cycle, “I don’t think there’s ever a moment when you’re not aware of the next performance. Everything affects the voice. Just being at all tired. And let’s face it, at certain times of the month for a woman, a cloudiness, a fuzziness, gets on the voice.”
Judy Garland is another singer cited in their study as a sufferer of PMS-related problems. In her adolescence she is said to have suffered with insomnia, mood swings and compulsive eating disorders. It is suggested that her PMS symptoms may have contributed to her alcohol and substance abuse.
Clearly then the emotional unreliability and volatility of a PMS sufferer can affect her career, often detrimentally. For an aspiring professional, “inappropriate” behavior and/or unreliability are inexcusable, suggesting that even today the severity of the psychological symptoms of PMS that affect singers and other professional voice users are not sufficiently understood. This need for recognition extends most significantly to those who guide and direct the musician’s artistic life and well-being, such as managers and artistic directors. In their summary, Davis and Davis draw relevant conclusions and advise singers to make certain allowances:
“While not using the syndrome as an excuse for poor performing, the singer must recognize that there will be physiological changes associated with the menstrual cycle that will prevent her from realizing her potential as an artist. At these times, education and acceptance of PMS will help her to avoid the self-doubt and needless guilt that often accompanies a disappointing performance…. Therefore, symptom management is necessary to survive in the competitive world of vocal performance. This involves realistic compensations, such as rest, dietary changes, exercise, medications, and adjustments in singing routines.”(1993:350)
This kind of attitude helps to validate issues related to PMS and their effect on the singer, which can only serve to overcome the lack of understanding that seems to dominate the community at large.
In recent times women are turning to more natural remedies. In keeping with this trend, the recommendation for use of herbs and natural therapies is favored by singers. My collaboration with naturopath Ruth Williams enabled us to compile a list of readily available items which may provide relief, or at least the stimulus for further investigation into this area These “Suggestions for Relief” are based on the specific symptoms addressed earlier in this article.
As stated previously, the most common physiological symptom caused by ovarian hormone fluctuation is hoarseness, due primarily to edema. The most aggressive remedies for this symptom would be the use of diuretics. Although their use may substantially relieve the fluid retention, many singers are hesitant to pursue this treatment because these drugs may irritate the mucosal surface of the vocal folds themselves. Other more dangerous side effects of diuretic use have been documented as consisting of:
“…vocal tremor, nervousness, cramping, fatigue, dizziness, permanent hearing impairment,… potentially dangerous dehydration and metabolic derangements…” Davis and Davis.(1993:344)
For a singer seeking alternatives, herbal remedies can provide relief without such severe side effects.
The Essential Fatty Acids (EFA) that occur naturally in evening primrose oil and fish oil can offer some relief. Williams maintains that:
“These essential fatty acids have an effect on steroid hormone activity including estrogen. If the hoarseness is an estrogen dependent condition, the EFAs are able to moderate the fluctuating hormonal effect on the larynx.” (1998)
EFAs also have strong anti-inflammatory action which would also be beneficial. Fluid retention, caused by estrogen excess and progesterone deficiency, was previously noted to affect the “support” mechanisms. To counteract these fluctuating levels, magnesium (mg) is offered as a remedy. Williams also recommends Vitamin B6 for aiding estrogen excess clearance. Naturopaths also recognize both items for their diuretic qualities and promotion of emotional well-being. Dandelion Leaf can also be used as a natural diuretic agent. Williams explains:
“Most orthodox diuretics will cause potassium to be lost through kidney stimulation. Dandelion leaf, however, is naturally high in potassium, so it replaces what is lost through diuresis.”
Dandelion leaf is readily available as an infusion (tea) from health food shops.
Vitamin C and bioflavonoids can improve the “integrity of connective tissue” (Williams 1998) which may help in the prevention of submucosal Hemorrhage. Deficiencies may result in:
“…defective formation and maintenance of collagen, ground substance and intercellular cement substance.”
Williams lists the following berries as being high in vitamin C and bioflavonoids: hawthorn berries, cherries, blueberries and blackberries, bringing to my attention that they are available in extract when not in season.
Cramping, constipation and diarrhea are usually due to muscular spasm of the lower abdominal region. Again magnesium is recommended, for its properties act to aid in the reduction of spasm in smooth muscle structures. Williams lists some herbal alternatives:
Cramp Bark—for its specific ability to relieve uterine spasm and muscle tension.
Black Cohosh—a North American indian herb known for its effects on normalizing ovarian hormone fluctuation. Also a relief for muscle and nerve pain.
Chaste Tree—has a stimulating and normalizing effect on the function of the pituitary gland, especially with regard to progesterone. It is also an effective herb for alleviating dysmenorrhoea and other symptoms relating to hormone fluctuation.
Stress Management is important for the overall well being of the performer in general. Recommendations for the implementation of relaxation (time out for oneself), meditation and/or yoga and exercise as part of a singer’s preparation regime were made in order to further help with the effects of the menstrual cycle.
Diet, too, plays an enormous role in a singer’s management of PMS (this subject would be a paper in itself), and I advise all performers to look into this aspect of their lifestyle with a practitioner with whom they can devise a suitable proposal.
Clearly then, there is a need for awareness of and experimentation with managing the debilitating effects of PMS on the singer. Perhaps by addressing some of the issues of relief as part of this study, interest will be heightened and a more specialist treatment of this area will emerge.
In conclusion, the effects of the Menstrual Cycle on the female singing voice is a highly complex one, embracing physiological, psychological, cultural and deeply personal factors. The latter of which will always defy those who choose a highly scientific approach to an intensely human characteristic.
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