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The Effects of Hormonal Contraception on the Voice: History of its Evolution in the Literature.

[Modified from J. Rodney and R.T. Sataloff, "The Effects of Hormonal Contraception on the Voice: History of its Evolution in the Literature," Journal of Voice 30, no. 6 (November 2016): 726-730; with permission.]

INTRODUCTION: THE MENSTRUAL CYCLE AND THE VOICE

The fluctuation of hormones in the menstrual cycle has significant effects on the voice. (1) Singing teachers should be familiar with the vocal effects of hormones and of hormonal medications such as oral contraceptives (birth control pills), especially in light of recent changes in their chemistry and effects. Vocal symptoms, known as dysphonia premenstrualis, accompany the better known symptoms of premenstrual syndrome (PMS) during the luteal phase of the menstrual cycle. (2) The most common symptoms of dysphonia premenstrualis are difficulty singing high notes, decreased flexibility, huskiness, fuzziness, breathiness, decreased volume, difficulty bridging passaggios and intonation problems. (3) Davis and Davis concluded that, on average, singers experience 33 general symptoms of PMS and 3 symptoms of dysphonia premenstrualis. (4) Chae et al. showed that approximately 57% participants met the DSM IV criteria for PMS and also had acoustic evidence of dysphonia premenstrualis, whereas the PMS-negative group did not. (5) The risk of vocal stress and possible damage during the premenstrual period led many European opera houses to offer singers contracts that included "grace days" during their premenstrual period. This accommodation is no longer followed in Europe and was never practiced generally in the United States. (6)

The mechanisms that cause these symptoms lie not just in the actions of the hormones themselves, but also in the cyclic fluctuation of hormone levels. The actions of the hormones on the vocal folds can be correlated with their effects on cervical mucus production. Cervical mucus in the preovulatory or follicular phase is thinner and slippery to aid insemination, while in the premenstrual or luteal phase it is thicker and more viscous. (7) Receptors for estrogen and progesterone have been identified in vocal fold mucosa. (8) Increased estrogen causes increased vocal fold mucus secretions and reduced mucosal viscosity and may increase vocal fold mass or thickness. Estrogen levels are highest in the follicular phase or preovulatory phase. Increased progesterone causes decreased mucus secretions, dehydration of the mucosa and lamina propria, increased mucous viscosity, associated with decreased mass or thinning of vocal fold mucosa. Progesterone levels are highest during the premenstrual phase or luteal phase. (9) Dehydration and thinning of the vocal folds in the premenstrual phase contributes to the symptoms of dysphonia premenstrualis.

The Physiology of the Menstrual Cycle

The menstrual cycle begins with approximately 5 days of menstrual flow. Both estrogen and progesterone levels are low during the menstruation phase. The follicular phase follows, in which the level of estrogen increases daily until day 14 when ovulation occurs, triggered by a surge in luteinizing hormone (LH). The luteal phase follows in which the estrogen level quickly decreases to mid-level. It plateaus there until the end of the cycle, when it drops quickly prior to menstrual flow. Progesterone remains low after the fifth day of menstrual flow. After ovulation, the progesterone level rises steadily to reach a peak halfway through the luteal phase. Then progesterone starts to decrease and reaches its lowest level prior to menstrual flow. (10)

The Physiology of Oral Contraception

Oral contraceptive pills (OCPs) reduce the overall fluctuation of hormones during the menstrual cycle that results in the depression of ovarian function. They function by feedback inhibition of hypothalamic secretion of gonadotropin releasing hormone (GnRH). The progesterone derivative also suppresses LH secretion from the anterior pituitary, which prevents ovulation. The estrogen derivative suppresses FSH secretion from the anterior pituitary, which inhibits follicle growth prior to ovulation. The major suppression of ovulation is accomplished by the progesterone derivative of the OCP. However, most pills combine estrogen and progesterone derivatives. The estrogen component has a role in the suppression of ovulation, but the progestin component alone would perform this task. The estrogen component stabilizes the endometrium, minimizing breakthrough bleeding. It also potentiates the action of the progestin component, allowing the dose of progestin in the pill to be reduced. The combination pill is generally more popular among women, but the progestin-only method is prudent in women at increased risk for cardiovascular and thromboembolic events. (11)

OCPs are either monophasic or multiphasic. Monophasic pills have the same formulation for 21 days of the cycle, followed by 7 placebo pills. Monophasic pills introduce the lowest levels of estrogen and progesterone needed to inhibit ovulation. Multiphasic (typically triphasic) OCPs attempt to mimic the fluctuation in hormones of the menstrual cycle. Their aim is to lessen the metabolic effects of the drugs and decrease the incidence of breakthrough bleeding and amenorrhea. Given the higher cost, greater complexity of triphasic pills in administration, and lack of evidence of a significant benefit of triphasic pills, monophasic pills are currently recommended as the first choice for initiation of oral contraception, by the Cochrane Database of Systematic Reviews. (12)

HISTORY OF ORAL CONTRACEPTION AND THE VOICE

The first OCP, Enovid[R] (G. D. Searle Co., Chicago), was tested in 1957 in Japan and Puerto Rico in a formulation containing 75 [micro]g of mestranol and 10 mg of norethynodrel. The dose was lowered to 5 mg norethynodrel prior to being sold in the United States in 1960. (13) Mestranol was found to increase thromboembolism risk. Norethynodrel is a nortestosterone derivative that has androgenic and metabolic effects that include voice virilization. (14) The second generation oral contraceptive developed in the 1970s included a progestin derivative, levonorgestrel (LNG), that allowed inhibition of ovulation at a lower dose. Many of the new, standard, low dose pills contain 100 to 250 [micro]g of LNG combined with 20 to 50 [micro]g of ethinylestradiol. The second generation OCPs began being marketed in the late 1960s and are, to this day, the most popular contraceptive option for women. (15) The 1980s brought the third generation progestins, gestodene and desogestrel. They are less androgenic and thus, result in decreased impact on metabolism, weight gain, acne, and mood changes. Drospirenone, a spironolactone derivative without androgenic effect and with antimineralocorticoid effect, is the progestin component in fourth generation contraceptives released in 2006. Controversy remains as to the safety of third and fourth generation progestins, as some data have shown an increase in thromboembolism risk. As a result, they are not used as frequently as LNG. (16)

Through the 1980s, the voice community believed strongly that oral contraceptives were damaging to some female voices, resulting in hoarseness, loss of vocal efficiency, lowering of range and loss of high notes. It was said that these permanent effects could occur after only a few months of therapy. (17) Ovosiston (2mg chlormadinone acetate, 0.1 mg mestranol) was shown in 1969 to be associated with a lower mean speaking frequency by 0.8 half-tone as well as an increase in vocal intensity by 5dB in lower third of pitch range. (18) Due to findings such as these, oral contraceptives were recommended only to alter the timing of menstruation to allow for crucial performances and occasionally to lower cyclical recurrent hemorrhage. The voice was to be monitored closely when oral contraceptives were in use. (19)

Studies since have found that first generation contraceptives containing a high dose nortestosterone derivative did cause virilization of the voice. However, second and third generation contraceptives are of a lower dose and do not have a deleterious effect on the voice. (20) First generation progestins are no longer used in the United States and, thus, the long held belief that OCPs are harmful to the voice has been refuted. (21)

THE EVIDENCE

Twenty-four articles were identified that address the effects of oral contraception on the vocal folds. The overall conclusion is that oral contraceptive pills do not affect the voice negatively. In fact, current OCP formulations tend to stabilize the singing voice through dampening of hormonal variation throughout the menstrual cycle. (22) However, the quantity and quality of the evidence are not ideal. There were many inconsistencies between the studies, as well as other shortcomings. Moreover, only combined oral contraceptives have been studied. There are many other forms of hormonal contraception used commonly by women on which there is no literature delineating their effects on the voice. There is also no evidence comparing monophasic to triphasic oral contraceptives.

Most of the literature investigated sustained vowel production. One study evaluated a German lied while others evaluated various vowels or vowel combinations. (23) The formant frequencies of each vowel differ, which theoretically would affect the objective measures used to analyze the voice. No comparison has been made between the various vowels studied in the literature as they relate to hormonal contraception on the voice.

Only five of the studies assessed connected speech, (24) one of which measured both sustained vowels and connected speech. (25) While sustained vowels generally showed a stabilizing affect with OCPs, connected speech did not show a significant difference in most of the literature. However, a study by Meurer et al. using connected speech did show increased frequency variation and intensity in OCP users. The evidence prior to this study had shown the changes in the vocal folds induced by OCPs not to be sufficient to affect connected speech. However, this new evidence suggests that there might be hormone mediated changes in connected speech. The evidence more strongly supports that the sustained vowels in singing are affected by hormonal contraceptives. (26)

The phase of the menstrual cycle that was analyzed was not standardized in the literature. Some of the studies measured acoustic or aerodynamic criteria only during ovulation, while others evaluated hormone levels during one, two, or all three phases of the cycle. (27) The difference between hormone levels of a participant using an OCP versus placebo varies at different time points in the cycle. Ideally, the measurements should be compared during all three phases to compare the differences in hormone levels in OCP versus non-OCP users from phase to phase. The conclusions that have been drawn based on the effects of the hormones have likely been affected by this variable.

Most investigations have assessed nonprofessional voice users. Some did not list the voice experience of the participants, and few included participants who were classically trained singers. The ability of a singer to compensate for changes in the vocal folds and perform well despite being compromised physically is one of the differences between a good singer and a great singer. There may have been hormone induced changes that occurred in the vocal folds in some singers, but their ability to modify the vocal tract to compensate for the change may have obscured the results. A well designed study that compares singers of different calibers on and off of oral contraceptives would distill this possible confounding variable.

The parameters measured vary greatly in the literature. Most investigations used acoustic parameters, including vibrato rate, vibrato extent, signed deviation from pure octave, speaking fundamental frequency, speaking fundamental frequency standard deviation, mean fundamental frequency, jitter (frequency variation), shimmer (amplitude variation), noise-to-harmonic ratio, percentage of irregularity in the frequency of the vocal fold vibration, percentage of irregularity in the amplitude of the vocal fold vibration, dynamic range, mean speaking frequency, amplitude perturbation quotient, signal to noise ratio, sound pressure level, ratio of amplitude of first harmonic to second, ratio of amplitude of first harmonic to first formant, and abruptness of vocal fold closure. (28) Dysphonia severity index used in one study was determined from maximum phonation time, highest frequency, lowest intensity, jitter and shimmer. One study used a rating scale of the quality of the voice judged by speech language pathologists. (29) Only two studies used aerodynamic parameters for analysis including subglottal pressure magnitudes, laryngeal airway resistance, peak flow, minimum flow, and alternating flow. (30) Each parameter varies in its sensitivity to detect changes in the voice as does the particular software program that measures it. (31) The lack of standardization of the parameters used to evaluate the voice, as well as limitations in the sensitivity, validity, and reliability of acoustic and aerodynamic measures, limit the conclusions that can be drawn from the literature.

An example of the significant impact that the parameters measured may have on the conclusions of a study highlights the problem. Two studies by the same author evaluated blood serum concentration of sex hormones including estrogen, progesterone, and testosterone compared to specific acoustic voice parameters. These studies were expected to confirm prior findings that the variation in hormone concentrations should cause increased perturbation in acoustic parameters. However, it was unexpected to find that the variations in hormones were not reflected by pitch variability in participants using placebo. Conversely, those using OCPs had increased variability in intonation compared with placebo users only at the [F.sub.5] pitch, the area of the soprano passaggio. The vibrato rate was slowed in OCP users as well, but not vibrato extent. Since the other studies measured neither vibrato rate nor vibrato extent, the results may have been a unique effect of OCPs on those parameters. The tenuity of the passaggio at [F.sub.5] may have rendered it susceptible to disturbance by once the normal flow of hormones, or it might prove idiosyncratic to this investigation; further research is needed to confirm or refute the findings reported in this study. This study suggests that changes in the vocal folds related to OCPs generally do not affect the classically trained voice except for the delicate passaggio region in which the slightest hormone variations might affect pitch control. (32) The author also pointed out that it may be the interaction of sex hormones, including testosterone, rather than the hormones individually that contribute to vocal fold changes. The suppression of testosterone by OCPs may play a bigger role in vocal fold fluctuation than was previously thought. (33)

For many years, it was thought that drospirenone, the progestin component in fourth generation OCPs, would avoid the androgenic effects that occur with other progestin derivatives. Drospirenone has been shown to counteract weight gain in opposition to the fluid retention that estrogen induces. (34) Thus, it was theorized that drospirenone-containing oral contraceptive would cause less perturbation in acoustic parameters resulting in an improved voice. Amir was the first to determine that the difference in the type of progestin component of an OCP does not, in fact, have a beneficial affect on the voice compared to other progestin derivatives. (35)

The physical characteristics of the participants have not been given enough consideration in most published research. Abitbol astutely considered fat composition of the patients the effect of exogenous hormones. Estrogen production takes place in adipose cells. Thinner women have less adipose tissue producing estrogen than heavier women. (36) Although the patient weight mean and range were listed in many studies, there was no analysis of weight or BMI compared with the hormonal changes. The contribution of body composition to sensitivity to exogenous hormones remains largely unknown. The ages of the women included in these studies are largely in their early twenties. Davis showed that PMS symptoms were less frequent and severe in women older than 35 years compared with those reported by younger women. (37) One might suspect, therefore, that older singers are either not as sensitive to hormonal changes, or their voices at baseline have deepened, resulting in less noticeable hormonal affect. The hormonal changes that occur later in life, especially peri- and postmenopausal, likely would affect the results and should be addressed in future research. Because La's studies of effects of OCPs included almost exclusively sopranos, conclusions drawn from the studies cannot necessarily be translated to singers of other Fachs. (38) There has been no investigation into the nuances of the mezzo soprano voice and the related susceptibility to hormonal changes.

The literature also has not yet included the contribution that auditory feedback plays in vocal acuity and control. A baseline audiogram was not measured in any of the studies; a hearing deficit could affect the ability to control the voice. PMS has been shown to cause sound hypersensitivity, hypersensitivity to a repetitive rhythmic pattern, vertigo, tinnitus, and recurring transient deafness. One study reported that some patients with "perfect pitch" lost that ability during the premenstrual period. (39) Compartmental fluid redistribution may contribute to the auditory symptoms related to PMS. (40) Estrogen receptors have been found in the inner ear, specifically the spiral ganglion type I cells, stria vascularis, and cochlear blood vessels. (41) Progesterone acts indirectly on the inner ear via steroid binding sites on GABA-A receptors in the auditory system. (42) These complex interactions were rarely mentioned and not included in analysis. Further research should include on consideration of the auditory and neurologic contributions to the voice and their hormone-related variations.

Oral contraceptive pills are sometimes prescribed off-label for other indications including polycystic ovarian syndrome (PCOS), endometriosis, and uterine leiomyoma. (43) Danazol, a drug historically used as a treatment for endometriosis, is not standard of care currently due to evidence of androgenic effects including pitch lowering. It is currently used for emergency contraception, but the effects on the voice for this indication have not been studied. Gestrinone, another drug used for emergency contraception, has been shown to cause subjective hoarseness when used for at least 6 months for the indication of endometriosis and uterine leiomyoma. (44) Oral contraceptives used for the purpose of emergency contraception likely would not show a perceptible difference in the voice given the short term use of the drug for this indication. One study showed no subjective voice change in users of the progestin, dienogest, to treat endometriosis. (45) No other investigations have been performed to evaluate the voice after treatment with low dose oral contraceptive therapy in these patient populations. It would be difficult to isolate the effects of oral contraception on the voice in patients with PCOS because the disease process, itself, can cause pitch lowering and instability. (46)

CONCLUSIONS

OCPs currently used today in the United States appear safe to administer to vocalists and likely stabilize the singing voice. The vast majority of the evidence demonstrates decreased pitch and volume variation with increased clarity of the singing voice with OCP use. There is little evidence to show a significant effect of hormonal contraception on speech. Testosterone may play a larger role in hormonally mediated voice changes than previously thought. However, multiple inconsistencies are present that weaken the evidence.

The literature has not addressed the effects of forms of hormonal contraception on the voice other than oral contraception such as intrauterine devices, patches, rings, and implants. Little evidence exists that compares different types of oral contraceptives. Many of the physical attributes of the singers were either not controlled or not factored into the analysis including Fach, vocal ability, age, and weight. Hormonal alterations of auditory feedback have not been assessed as they relate to contraception. With these deficiencies in mind, randomized, double blind, controlled trials with adequate statistical power should be encouraged to elucidate the full scope of their effects on the voice.

NOTES

(1.) O. Amir, L. Kiston-Rabin, and C. Muchnik, "The effect of oral contraceptives on voice: preliminary observations," Journal of Voice 16, no. 2 (June 2002): 267-273; O. Amir and L. Kiston-Rabin, "Association between birth control pills and voice quality," The Laryngoscope 114, no. 6 (June 2004): 1021-1026; J. Abitbol, P. Abitbol, and B. Abitbol, "Sex hormones and the female voice," Journal of Voice 13, no. 3 (September 1999): 424-446; M.B. Higgins and J.H. Saxman, "Variations in vocal frequency perturbation across the menstrual cycle," Journal of Voice 3, no. 3 (September 1989): 233-243; S. Whiteside, R. Dobbin, and L. Henry, "Sex differences in voice onset time: a developmental study of phonetic context effects in British English," Journal of the Acoustical Society of America 116, no. 2 (August 2004): 1179-11183.

(2.) S. Kadakia, D. Carlson, and R. Sataloff, "The effect of hormones on the voice," Journal of Singing 69, no. 5 (May/June 2013): 571-574.

(3.) Ibid; C. Davis and M. Davis, "The effects of premenstrual syndrome (PMS) on the female singer," Journal of Voice 7, no. 4 (December 1993): 337-353.

(4.) Ibid.

(5.) S.W. Chae et al., "Clinical analysis of voice changes as a parameter of premenstrual syndrome," Journal of Voice 15, no. 2 (June 2001): 278-283.

(6.) J. Rubin, R. Sataloff, and G. Korovin, eds., Diagnosis and Treatment of Voice Disorders, 4th edition (San Diego, CA: Plural Publishing, Inc., 2014).

(7.) S. Sonalkar, C. Schreiber, and K. Barnhart, "Contraception," in L. J. DeGroot et al., eds., Endotext [Internet] (South Dartmouth, MA: MDText.com, Inc., 2000); https://www.ncbi.nlm.nih.gov/books/NBK279148/.

(8.) J. Abitbol, P. Abitbol, and B. Abitbol.

(9.) R. Morris, M. Gorham-Rowan, and K. Herring, "The effect of initiating oral contraceptive use on voice: a case study," Journal of Voice 25, no. 2 (March 2011): 223-229; R. Morris, M. Gorham-Rowan, and K. Herring, "Voice onset time in women as a function of oral contraceptive use on the voice: a case study," Journal of Voice 23, no. 1 (January 2009): 114-118; L. Speroff and P. Darney, A Clinical Guide for Contraception, 5th edition (Philadelphia, PA: Lippincott Williams and Wilkins, 2011).

(10.) A. E. Walker, The Menstrual Cycle (New York, NY: Routledge, 1997).

(11.) Sonalkar, Schreiber, and Barnhart; Speroff and Darney; Walker.

(12.) H. A. Van Vliet et al., "Triphasic versus monophasic oral contraceptives for contraception," Cochrane Database of Systemic Reviews no. 11 (November 2011): CD003553.

(13.) M. Dhont, "History of oral contraception," European Journal of Contraception and Reproductive Health Care 15, Suppl. 2 (December 2010): S12-S18.

(14.) J. Abitbol, P. Abitbol, and B. Abitbol.

(15.) Dhont; J. Jones, W. Mosher, and K. Daniels, "Current contraceptive use in the United States, 2006-2010, and changes in patterns of use since 1995," National Health Statistics Report no. 60 (October 2012): 1-25; G. Benagiano, S. Carrara, and V. Filippi, "Safety, efficacy, and patient satisfaction with continuous daily administration of levonorgestrel/ethinylestradiol oral contraceptives," Patient Preference and Adherence 3 (November 2009): 131-143.

(16.) Dhont; C. Ellertson, "History and efficacy of emergency contraception: beyond Coca-Cola," Family Planning Perspectives 28, no. 2 (March/April 1996): 44-48.

(17.) R. Sataloff, "Professional singers: the science and art of clinical care," American Journal of Otolaryngology 2, no. 3 (August 1981): 251-266.

(18.) J. Wendler et al., "The influence of Microgynon and Diane-35, two sub-fifty ovulation inhibitors, on voice function in women," Contraception 52, no. 6 (December 1995): 343-348; J. Wendler, "Zyklusabhangige Leistungsschwankungen der Stimme und ihre Beeinflussung durch Ovulationshemmer," Folia Phoniatrica 24, no. 4 (1972): 259-277.

(19.) Rubin, Sataloff, and Korovin; Sataloff; Wendler et al.; Wendler; M. Schiff, "'The pill' in otolaryngology," Transactions--American Academy of Ophthalmology and Otolaryngology 72, no 1 (January/February 1968): 76-84; F. Brodnitz, "Hormones and the human voice," Bulletin of the New York Academy of Medicine 47, no. 2 (February 1971): 183-191; F. La et al., "The Effects of a Third Generation Combined Oral Contraceptive Pill on the Classical Singing Voice," Journal of Voice 21, no. 6 (November 2007): 754-761.

(20.) Amir, Kiston-Rabin, and Muchnik; Amir and Kiston-Rabin; Higgins and Saxman; Whiteside, Dobbin, and Henry; Kadakia, Carlson, and Sataloff; Rubin, Sataloff, and Korovin; Morris, Gorham-Rowan, and Herring, "The effect of initiating oral contraceptive use on voice"; Morris, Gorham-Rowan, and Herring, "Voice onset time in women as a function of oral contraceptive use on the voice"; F. La et al., "The Effects of a Third Generation Combined Oral Contraceptive Pill on the Classical Singing Voice," Journal of Voice 21, no. 6 (November 2007): 754-761; O. Amir et al., "Do oral contraceptives improve voice quality? Limited trial on low-dose formulations," Obstetrics and Gynecology 101, no. 4 (April 2003): 773-777; M. Gorham-Rowan et al., "Vocal pitch levels during connected speech associated with oral contraceptive use," Journal of Obstetrics and Gynaecology 24, no. 3 (April 2004): 284-286; F. La et al., "Effects of the menstrual cycle and oral contraception on singers' pitch control," Journal of Speech, Language, and Hearing Research 55, no. 1 (February 2012): 247-261; M. Gorham-Rowan and L. Fowler, "Laryngeal aerodynamic associated with oral contraceptive use: Preliminary findings," Journal of Communication Disorders 42, no. 6 (November/December 2009): 408-413; M. Gorham-Rowan, "Acoustic measures of vocal stability during different speech tasks in young women using oral contraceptives: a retrospective study," The European Journal of Contraception and Reproductive Health Care 9, no. 3 (September 2004): 166-172; M.

Gorham-Rowan and L. Fowler, "Aerodynamic assessment of young women's voices as a function of oral contraceptive use," Folia Phoniatrica et Logopaedica 60, no. 1 (February 2008): 20-24; O. Amir, T. Biron-Shental, and E. Shabtai, "Birth control pills and nonprofessional voice: acoustic analysis," Journal of Speech, Language, and Hearing Research 49, no. 5 (October 2006): 1114-1126; O. Amir et al., "Different oral contraceptives and voice quality--an observational study," Contraception 71, no. 5 (May 2005): 348-352; O. Amir and T. Biron-Shental, "The impact of hormonal fluctuations on female vocal folds," Current Opinion in Otolaryngology and Head and Neck Surgery 12, no. 3 (June 2004): 180-184; F. La et al., "Oral contraceptive pill containing drospirenone and the professional voice: an electrolaryngographic analysis," Logopedics Phoniatrics Vocology 34, no. 1 (July 2009): 11-19; K. Van Lierde et al., "Response of the female vocal quality and resonance in professional voice users taking oral contraceptive pills: a multiparameter approach," Laryngoscope 116, no. 10 (October 2006): 1894-1898.

(21.) Chae et al.

(22.) Amir, Kiston-Rabin, and Muchnik; Amir and Kiston-Rabin; La et al., "The Effects of a Third Generation Combined Oral Contraceptive Pill on the Classical Singing Voice"; Amir et al., "Do oral contraceptives improve voice quality?"; Gorham-Rowan et al; La et al., "Effects of the menstrual cycle and oral contraception on singers' pitch control"; Gorham-Rowan and Fowler, "Laryngeal aerodynamic associated with oral contraceptive use"; Gorham-Rowan; Gorham-Rowan and Fowler, "Aerodynamic assessment of young women's voices as a function of oral contraceptive use"; Amir, Biron-Shental, and Shabtai; Amir et al., "Different oral contraceptives and voice quality--an observational study"; Amir and Biron-Shental; La et al., "Oral contraceptive pill containing drospirenone and the professional voice"; Van Lierde et al.

(23.) Amir, Kiston-Rabin, and Muchnik; Amir and Kiston-Rabin; Wendler et al; Wendler; Schiff; Brodnitz; La et al., "The Effects of a Third Generation Combined Oral Contraceptive Pill on the Classical Singing Voice"; Amir et al., "Do oral contraceptives improve voice quality?"; Gorham-Rowan et al; La et al., "Effects of the menstrual cycle and oral contraception on singers' pitch control"; Gorham-Rowan and Fowler, "Laryngeal aerodynamic associated with oral contraceptive use"; Gorham-Rowan; Gorham-Rowan and Fowler, "Aerodynamic assessment of young women's voices as a function of oral contraceptive use"; Amir, Biron-Shental, and Shabtai; Amir et al., "Different oral contraceptives and voice quality- an observational study"; Amir and Biron-Shental; La et al., "Oral contraceptive pill containing drospirenone and the professional voice"; Van Lierde et al; E. Meurer et al., "Speech articulation of low-dose oral contraceptive users," Journal of Voice 29, no. 6 (November 2015): 743-750.

(24.) Morris, Gorham-Rowan, and Herring, "Voice onset time in women as a function of oral contraceptive use on the voice"; Gorham-Rowan et al; Gorham-Rowan and Fowler, "Laryngeal aerodynamic associated with oral contraceptive use"; Gorham-Rowan.

(25.) Meurer et al.

(26.) Morris, Gorham-Rowan, and Herring, "Voice onset time in women as a function of oral contraceptive use on the voice"; Gorham-Rowan et al; Gorham-Rowan and Fowler, "Laryngeal aerodynamic associated with oral contraceptive use"; Gorham-Rowan; Meurer et al.

(27.) Amir, Kiston-Rabin, and Muchnik; Amir and Kiston-Rabin; Higgins and Saxman; Whiteside, Dobbin, and Henry; Kadakia, Carlson, and Sataloff; Rubin, Sataloff, and Korovin; Morris, Gorham-Rowan, and Herring, "The effect of initiating oral contraceptive use on voice"; Morris, Gorham-Rowan, and Herring, "Voice onset time in women as a function of oral contraceptive use on the voice"; La et al., "The Effects of a Third Generation Combined Oral Contraceptive Pill on the Classical Singing Voice"; Amir et al., "Do oral contraceptives improve voice quality?"; Gorham-Rowan et al; La et al., "Effects of the menstrual cycle and oral contraception on singers' pitch control"; Gorham-Rowan and Fowler, "Laryngeal aerodynamic associated with oral contraceptive use"; Gorham-Rowan; Gorham-Rowan and Fowler, "Aerodynamic assessment of young women's voices as a function of oral contraceptive use"; Amir, Biron-Shental, and Shabtai; Amir et al., "Different oral contraceptives and voice quality--an observational study"; Amir and Biron-Shental; La et al., "Oral contraceptive pill containing drospirenone and the professional voice"; Van Lierde et al; E. Meurer et al.

(28.) Amir, Kiston-Rabin, and Muchnik; Amir and Kiston-Rabin; Morris, Gorham-Rowan, and Herring, "The effect of initiating oral contraceptive use on voice"; Morris, Gorham-Rowan, and Herring, "Voice onset time in women as a function of oral contraceptive use on the voice"; La et al., "The Effects of a Third Generation Combined Oral Contraceptive Pill on the Classical Singing Voice"; Amir et al., "Do oral contraceptives improve voice quality?"; Gorham-Rowan et al; La et al., "Effects of the menstrual cycle and oral contraception on singers' pitch control"; Gorham-Rowan and Fowler, "Laryngeal aerodynamic associated with oral contraceptive use"; Gorham-Rowan; Gorham-Rowan and Fowler, "Aerodynamic assessment of young women's voices as a function of oral contraceptive use"; Amir, Biron-Shental, and Shabtai; Amir et al., "Different oral contraceptives and voice quality- an observational study"; Amir and Biron-Shental; La et al., "Oral contraceptive pill containing drospirenone and the professional voice"; Van Lierde et al; E. Meurer et al.

(29.) Van Lierde et al.

(30.) Gorham-Rowan and Fowler, "Laryngeal aerodynamic associated with oral contraceptive use"; Gorham-Rowan and Fowler, "Aerodynamic assessment of young women's voices as a function of oral contraceptive use."

(31.) S. Freitas et al., "Integrating voice evaluation: correlation between acoustic and audio-perceptual measures," Journal of Voice 29, no. 3 (May 2015): 390.e1-390.e7; G. DeKrom, "Consistency and reliability of voice quality ratings for different types of speech fragments," Journal of Speech, Language, and Hearing Research 37, no. 5 (October 1994): 985-1000; J. Hillenbrand, R. A. Cleveland, and R. L. Erickson, "Acoustic correlates of breathy vocal quality," Journal of Speech, Language, and Hearing Research 37, no. 4 (August 1994): 769-778.

(32.) La et al., "Effects of the menstrual cycle and oral contraception on singers' pitch control"; La et al., "Oral contraceptive pill containing drospirenone and the professional voice."

(33.) Ibid; Ibid; Y. Zimmerman et al., "The effect of combined oral contraception on testosterone levels in healthy women: a systematic review and meta-analysis," Human Reprodroduction Update 20, no. 1 (January/February 2014): 76-105.

(34.) I. Thorneycraft, "Yasmin: the reason why," The European Journal of Contraception and Reproductive Health Care 7, Suppl. 3 (December 2002): 13-18.

(35.) Amir, Kiston-Rabin, and Muchnik; Amir et al., "Different oral contraceptives and voice quality--an observational study."

(36.) J. Abitbol, P. Abitbol, and B. Abitbol.

(37.) C. Davis and M. Davis.

(38.) La et al., "Effects of the menstrual cycle and oral contraception on singers' pitch control"; La et al., "Oral contraceptive pill containing drospirenone and the professional voice."

(39.) C. Davis and M. Davis.

(40.) J. Andrews, G. Ator, and V. Honrubia, "The exacerbation of symptoms in Meniere's disease during the premenstrual period," Archives of Otolaryngology--Head and Neck Surgery 118, no. 1 (January 1992): 74-78.

(41.) A. Stenberg et al., "Mapping of estrogen receptors alpha and beta in the inner ear of mouse and rat," Hearing Research 136, nos. 1-2, (October 1999): 29-34.

(42.) D. Al-Mana et al., "Hormones and the auditory system: a review of physiology and pathophysiology," Neuroscience 153, no. 4 (June 2008): 881-900.

(43.) M.A. Pattie et al., "Voice changes in women treated for endometriosis and related conditions: the need for comprehensive vocal assessment," Journal of Voice 12, no. 3 (September 1998): 366-371; E. M. Coutinho and G. Azadian-Boulanger, "Treatment of endometriosis by vaginal administration of gestrinone," Fertility and Sterility 49, no. 3 (March 1988): 418-422; E. M. Coutinho and M. T. Goncalves, "Long-term treatment of leiomyomas with gestrinone," Fertility and Sterility 51, no. 6 (June 1989): 939-946; K. Kaminski et al., "Treatment of endometriosis with dienogest: preliminary report," Ginekologia Polskie Towarzystwo Ginekologiczne 72, no. 5 (May 2001): 299-304; A. Hannoun et al., "Vocal changes in patients with polycystic ovary syndrome," Journal of Voice 25, no. 4 (July 2011): 501-504.

(44.) Pattie et al; Coutinho and Azadian-Boulanger; Coutinho and Goncalves.

(45.) Kaminski et al.

(46.) Hannoun et al.

Jennifer Rodney is currently a Fellow in Laryngology and Care of the Professional Voice at Vanderbilt University Medical Center. She graduated from the University of South Florida, double majoring in Biomedical Science and Music Studies with an Emphasis in Vocal Performance. She completed medical school at the University of Florida and residency in otolaryngology--head and neck surgery at The University of Oklahoma Health Sciences Center. She is a professional singer and looks forward to combining her two passions in her career as a laryngologist.
Memory, hither come,
  And tune your merry notes;
And, while upon the wind,
  Your music floats,
I'll pore upon the stream,
  Where sighing lovers dream,
And fish for fancies as they pass
  Within the watery glass.

I'll drink of the clear stream,
  And hear the linnet's song;
And there I'll lie and dream
  The day along:
And, when night comes, I'll go
  To places fit for woe,
Walking along the darken'd valley,
  With silent Melancholy.

        "Song: Memory, hither come,"
                       William Blake


Robert T. Sataloff, Associate Editor
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No portion of this article can be reproduced without the express written permission from the copyright holder.
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Title Annotation:CARE OF THE PROFESSIONAL VOICE
Author:Rodney, Jennifer; Sataloff, Robert T.
Publication:Journal of Singing
Article Type:Reprint
Geographic Code:1USA
Date:Mar 1, 2019
Words:5496
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