Singing Through Change

Women’s Voices in Midlife, Menopause, and Beyond

Nancy Bos
Joanne Bozeman
Cate Frazier-Neely
STUDIOBOS MEDIA
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Cover design by Christopher Bozeman
Cover art by Cate Frazier-Neely
✽✽✽
First published in 2020 by StudioBos Media
StudioBos Media
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Suquamish, WA 98392 USA
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ISBN: 9798622317644
ASIN: B08659YNSG
Copyright © StudioBos 2020
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This book was published in the middle of the COVID-19 health crisis. We find our title, Singing Through Change, is more on point than we could have imagined:
due to the world crisis, typical ear, nose, and throat care may not be available for a time except in medical emergencies. However, we have been advised that voice
care and consultations may be available via telemedicine or telepractice and through other online voice care providers. Contact your clinic for detailed information. We
will post updates and links to more resources on the Singing Through Change website, singingthroughchange.com.

✽✽✽
The information in this book is not intended to be used to diagnose or treat any medical or emotional condition. The content of this book is for informational purposes
only. The authors and publisher are not responsible for any conditions that require a licensed professional. The reader should regularly consult a physician in matters
relating to his/her health and particularly with respect to any symptoms that may require diagnosis or medical attention. The use of this book implies the reader’s
acceptance of this disclaimer.

Pseudonyms have been used for all of the interviewees.

Circumstances and details of their case studies have been changed to protect their privacy. Stories and quotations have been edited for brevity, clarity, and flow.
This book is dedicated to our mothers, daughters, and all women who sing. It is dedicated to the researchers who came before us and those who will follow.
It is also dedicated to the 56 singers who graciously and openly shared their stories of midlife, menopause, and
older age with us. Throughout the writing of the book, we continued to be struck by their willingness to walk us
through their vocal journeys, health issues, and the emotional challenges they faced.
FOREWORD
When I was asked to review this book and possibly write a foreword, I was anticipating a “how-to” manual for the menopausal woman. What I found was a collection
of unique lived experiences from every stage in an adult woman’s life, accompanied by equally unique and individualized solutions. The featured life experiences soon
resembled a choir of unified voices sending the message that it’s possible for voice changes at all stages of hormonal adjustments in a woman’s voice. Thankfully,
the life experience stories are accompanied in the book by well vetted strategies and resources. The authors offer both traditional and alternative medical solutions
for the reader.
Of course, dealing with a changing voice can be challenging and like any challenge in life, we get to decide how we react to that challenge. I read a quote from
John Henny, a voice colleague, who stated, “We spend so much time depressed about the past or anxious about the future that we often miss the miracle of the
present. Every moment you get to spend with your voice should be treasured and experienced fully.” The experiences of the women in this book embodied this
sentiment fully.
The book shares positive outcomes using a variety of strategies. Even women who can’t relate to any specific experience in the book should find hope to persist
in finding answers for specific challenges. With the right information and personal choice of treatment a woman can find confidence to continue to sing at every stage
of life and with its accompanying voice changes.
Postscript:
Yesterday in church I listened to a much older woman singing behind me. She was probably in her late 80s and though her voice may have been a bit wobbly and
not as secure as her younger voice, she sang with careless abandon. Before this book I may have listened with my normal “How can I fix that?” ears, but with my
post Singing Through Change ears, I thought to myself “What a lovely sound!” After the service I remarked to her that I loved hearing her beautiful voice singing
behind me. She replied with a smile “Well, it’s not what it used to be,” to which I said, “No it’s not. It’s what it is today and it is beautiful. Thank you for continuing
to share with us.”

Teri Stock, Singing Specialist and NCVS Trained Vocologist

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Teri and I can say together with one loud voice that Singing Through Change: Women ’ s Voices in Midlife, Menopause, and Beyond is a must-read for anyone who is a
singer, voice teacher, singing specialist, or medical professional. What an incredible resource for all those involved with voice in any way. As a practicing
Otolaryngologist I regret not having information such as this early on in my practice. Treating women with vocal problems has now become a much more complex
proposal as I take into consideration age, vocation, vocal use, and occupation. I have a new perspective on this complex issue of the never ending change my more
mature female voice patients deal with. The insight this book gives into this complex matter for those of us treating vocal problems is immeasurable. I now have
added extra time to fully evaluate my female voice patients as a direct result of the added knowledge gained from this opus. A thorough understanding of hormones
is incumbent on those of us dealing with female singers. Reading the experiences of women and additional insight given by the authors has totally changed my
approach and evaluation of mature women singers.
I appreciate women more than I ever have after reading this book, not just pertaining to voice, but to the obstacles in all aspects of life. Perhaps this should be a
must read for all men.

Dr. Curt R Stock, Otolaryngologist, NCVS trained Vocologist

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Teri Stock and her husband, Dr. Curt Stock, both trained vocologists through the National Center for Voice and Speech (NCVS), work as a voice team treating voice
problems in singers in Utah as well as other locations. Dr. Stock’s role is to diagnose and treat or recommend treatment. Often he then meets with the vocal team to
discuss treatment. At times, that team includes Teri Stock, a singing specialist. Teri’s role is to help those who have issues with singing and can include helping the
discuss treatment. At times, that team includes Teri Stock, a singing specialist. Teri’s role is to help those who have issues with singing and can include helping the

singer adjust to and accept a changed instrument.

CONTENTS

C ONTENTS

Singing Through Change

Foreword
Contents
Introduction
How the Book Began
What This Book is About
Why This Book is Important
Process and Approach
Understanding the Overall Hormonal Journey
Progress in Our Understanding
Empowering Women Who Sing
Singing Is My Identity
Sorting through Variables in Women’s Voices
Looking for the Cause of Vocal Challenges
Persist in Singing
Menopausal Voice Changes
The Benefits of Lifelong Singing
Sorting Out Complex Situations
Being Our Own Worst Critic
Stress Can Add to Vocal Issues
Self-Care Includes Singing
Developing Grounded and Compassionate Ways with Yourself
It is Worth It to Persist
Hormone Related Midlife Voice Changes
What Are Perimenopause and Menopause?
Perimenopausal and Menopausal Symptoms
How Often Do Our Voices Change?
How Hormonal Changes Impact the Singing Voice
Ties Between Hormones and the Voice
How Reproductive Hormones Affect the Voice
What Vocal Symptoms Have Been Reported?
Advocating for Yourself
Smooth Sailing
 Keep an Open Mind – Wait and See
Unfold in the Moment
Cross Training the Voice
Vocal Flexibility Through the Years
Classical Singing and Healthy Living
No Medications - Other than Chocolate
Looking for Commonalities
Rough Waters
A Perfect Storm for a Singer
Thyroid Issues
Career Changes through Hormonal Transition
Self-Blame Adds to the Struggle
The Emotional Connection
,
Laryngopharyngeal Reflux (LPR) and Gastroesophageal Reflux Disease (GERD)
Interconnected Influences on Singing
Singing Through the Hard Times
Music Makes Me Feel Better
Singing as a Healing Method
Singing Can Be the Reason for Recovery
Singing Before, During, and After Cancer
Singing with Vocal Fold Paresis
Complicated Vocal Challenges
Exploring Alternative Methods
Equine Assisted Therapy-Discovery, Strength, & Healing
Qigong for Recalibration and Focus
Alexander Technique and Other Body Work
Exploring Alternative Healing Methods
Finding Yourself on the Other Side
Mixed Emotions about Changes
Improvements to the High Range
Dealing with Vocal Fold Injury
What is a Vocal Fold Hemorrhage?
Minimizing the Risk of Vocal Fold Hemorrhage
Attitudes for Moving Through Changes
Singing Into Older Age
Physical Changes to the Aging Voice
Lowered Singing Range in Aging Voice
Relentless Vocal Tract Dryness
Dry Mouth and Throat
How Much Vocal Exercise is the Right Amount
Treating the Whole Person
Troubleshooting Complex Issues
Effects of Medications on the Voice
Asthma and Singing
Changes in How Singers Perceive Their Voices
Driven to Sing
Supporting Singers with Personal Obstacles
Where To Go From Here
Overlapping Issues Cause Complex Results
The Role of Reproductive Hormones in the Body
Knowing When to Work with Medical Professionals
Finding the Right Combination of Care
Advancing Research
Advocating For Ourselves
What to Look for in a Voice Teacher and Choir Director
Closing Thoughts
Appendices
Voice Care Doctors
Other Voice Caregivers
Related Organizations & Clinic/Practitioner Locators
Acknowledgments
Bibliography
About the Authors
Endnotes
INTRODUCTION
H OW THE B OOK B EGAN
Like many people, the three of us grew up singing in our communities and in school. We didn’t know each other, but we all sang through childhood, high school, and
college. Individually we each turned to performing and teaching as our life’s work, and all along the way we shared a deep love of learning.
We have performed in all of the common hormonal phases a female often experiences: puberty, menstruation, pregnancy, breastfeeding, perimenopause, and in
Cate’s and Joanne’s cases, postmenopause. We’ve also experienced singing through illness and phases of aging.
Cate and Joanne are both at the tail end of midlife. Joanne experienced confusing and frustrating voice changes from her late 40s through her late 50s. Cate's
difficulties, over many years, were the perfect storm of an unusually severe health history, hormonal imbalances, and the vocal issues that resulted. These
experiences shaped their lives. They have come to peace with what they went through, thanks to the knowledge and understanding gained through researching and
writing this book. They are now armed to optimize their singing through aging voice changes.
Nancy, the youngest of the three of us, has had good vocal health so far and has benefitted in “real time” as her voice went through some of the changes we’ve
studied. We now realize that all of her vocal adjustments, including some she previously blamed on a sudden, mysterious lack of skill, have been typical for many
women in menopausal transition.
We came together to write this book through what feels like fate. Barely knowing each other, we were drawn together through our professional relationships in
the Pan American Vocology Association, The Speakeasy Cooperative, and the National Association of Teachers of Singing. We soon learned that as individuals, our
skills were a perfect complement to each other. We have enjoyed working together for over two years and look forward to maintaining our now deep friendship for
the rest of our lives.
W HAT T HIS B OOK IS A BOUT
This book is meant to encourage and educate women worldwide who love to sing, to provide a reliable, readable resource, and to let them know they are not alone. In
the book we tell the individual stories of 56 women moving through voice changes. Some of the women report no physical challenges, but others reveal debilitating
voice issues. We include the solutions they found, and where possible, spell out definitions and descriptions of issues that may have been behind their struggles. We
highlight the individual women as models for what others might experience. Each woman’s vocal journey is unique, and in fact, many women will not notice any vocal
struggle. We included some of those stories as well.
Additionally, time and again, we heard from women who blamed themselves for changes as being signs of “poor technique” without considering all the physical
changes to their bodies. Women in this mindset rarely talk about what they have experienced, but several of them shared their troubles with us in these qualitative
interviews.
This is not a “How to Sing” book, and it is not a “How to Work with Singers” book for voice teachers and choral directors. Initially we thought we’d be writing a
book communicating what is understood about the effects of changing reproductive hormones as well as aging on the singing voice. We quickly realized that the
overall concept of perimenopause was poorly understood. The effects of hormone changes on the singing voice during the entire menopausal transition were even less
understood. We frequently came across the mistaken viewpoint that midlife and menopausal changes to the voice should always be placed under the umbrella of the
aging voice. They are separate biological processes that can overlap or not.
W HY T HIS B OOK IS I MPORTANT
In the United States and Europe, it is estimated that over 46 million women sing in choirs. [1] , [2] That is a jaw-dropping number. We can also consider that there are
millions of women in the rest of the world who sing in choirs. If we also count professional singers in all genres, and millions of committed amateur singers who
aren’t in choirs, we can easily estimate that hundreds of millions of women, if not billions, love to sing.
Additionally, in the United States alone 6,000 women reach menopause every day. [3] The U.S. Census Bureau tells us that over 71 million [4] women are in midlife,
between 45 and 65 years of age. The median age [5] of women in the United States is 39.5, which is in the range of when perimenopause starts. The average ages at
which natural menopause occurs worldwide are between 45-55. [6] Though uncommon, women can reach menopause in their late 30s.
Despite these impressive numbers, until fairly recently not much was understood about the evolving stages of the voice through the entire lifespan, or that the
years of menopausal transition can affect the voice dramatically. The hormone fluctuations of perimenopause are followed by a marked decline in estrogen and
progesterone around the time of menopause. This decline can result in voice changes. [7] Additionally, there can be overlap in voice changes between postmenopausal
symptoms and aging symptoms, but this is not always the case. It’s important to know that many women pass through their years of transition with little to no
physical symptoms and few singing and voice issues. For those who do experience singing issues, they can have a powerful impact on how women feel about their
ability to sing and even on their identity. Sometimes these voice changes have significantly impacted and even ended careers, through no fault of the singers. [8]
Aging voice is hard to define because the aging voice is more of a reflection of physiological age than chronological age, but typically researchers consider "older
age" to begin at 65. [9] Women are living almost twice as long as they did 100 years ago, [10] spending about 1/3 to 1/2 of their lives postmenopausal. [11] As we move
past the old age markers of previous generations, we find that we are in uncharted territory in developing a body of shared knowledge, experiences, and wisdom
regarding singing. This book helps build that body of knowledge through the voices of the women who freely shared their stories.
P ROCESS AND A PPROACH
The information in this book comes from three main sources of evidence:

Related research from the fields of medicine, voice science, and vocal pedagogy.

Qualitative research, gathered from our interviews with 56 cis-gender women, ages 40-88, as well as from other
sources.

Clinical opinions of voice professionals and singing teachers about female voice during the menopausal transition and
beyond.

We used the women’s stories as the vehicle to highlight medical and vocal health information. Our study represented a wide variety of musical genres and
singing experience levels. The vast majority of published research on voice and menopause does not differentiate speaking voice from singing voice. There are only
about five published studies that explore how menopause affects singers specifically, [12] but as valuable as they are, studies fall short of explaining the complex
interactions of hormone changes, aging, and the lived experiences of female singers. Several rigorous explorations have also been contributed by women in academia
in the last ten years.
This book is about women of both sex and gender. Sex refers to physiological distinctions such as reproductive organs, chromosomes and hormones, while gender
refers to experiences and expectations for those identifying as women. [13] Gender identity and sex don’t always match: women are living along a wide gender
spectrum. However, we do not currently have adequate data to address the needs of all experiences along the gender spectrum. Consequently, we use the word
“women” to refer to people who experience typical female reproductive hormonal shifts of menopause.
U NDERSTANDING THE O VERALL H ORMONAL J OURNEY
More and more, people have been questioning why relatively little is known about the menopausal transition and its effects on the mind, body and emotions. Compared
to males, illnesses in women are more slowly diagnosed and often blamed on psychological weakness. There is also a well-known and acknowledged history of gender,
ethnic, and economic-social bias in medical research which has yet to be righted. Thankfully, the situation is starting to improve, but we have a long way to go to
correct the origins and centuries of neglect, mistreatment, and imbalance of attention to women's health issues.
In presenting this material, we’ve felt compelled to help others understand the history of ignorance of the female midlife hormone changes. We needed to do this,
not only to understand some of the experiences of the older women we spoke with, but also to shine a light on instances where this ignorance is still holding women
back from living their best lives, and in some instances, doing real harm.
For example, according to science writer Ada McVean from McGill University, in modern culture “when we say someone is hysterical, we mean that they are
frenzied, frantic, or out of control.” [14] However, historically hysteria was categorized as a disease. Its symptoms were similar to normal menopausal symptoms.
From the Wikipedia entry, “Female Hysteria,” these included “anxiety, shortness of breath, nervousness, sexual desire, insomnia, fluid retention, heaviness in the
abdomen, irritability, loss of appetite for food or sex, and a ‘tendency to cause trouble for others’”. [15] Women in the mid-19th to early 20th centuries were
sometimes forced to permanently enter an insane asylum or to have a hysterectomy. It was thought that removing the uterus would “normalize” symptoms.
According to medical historian Louise Foxcroft, at least one Victorian gynecologist recommended tortuous remedies such as injections of acetate of lead into the
womb to supposedly control symptoms. Other solutions included bleeding by application of leeches and frequent use of opium and other sedatives. [16]
The word “hysteria” was dropped from the official Diagnostic and Statistical Manual of Mental Disorders in 1980. [17] At that time, sexist attitudes were still very
high in all fields of western medicine. Women were subjected to innuendo, incorrect or limited advice, condescending behavior, and dismissiveness. The language for
describing symptoms was not well developed, and many women didn’t know how to describe their symptoms. One of the women interviewed for this book, now in her
80s, said that when she was in her mid-40s, she told her gynecologist that three weeks out of the month she felt “like the molecules that are me are just floating
around in space,” which sounds like brain fog. She then told him, “The week I get my period is the only time I feel solid, like myself.” His illogical solution? To
perform a hysterectomy (surgical removal of the uterus), which at that time meant a two week stay in the hospital.
Thankfully, since then the medical field and culture in general, in many parts of the world, have made progress in understanding menopause and treating
symptoms appropriately. But this isn’t the case everywhere. Shadows of ignorance and prejudice linger about the natural progression of the female life cycle. One
positive change is that some scientists are calling for the removal of the word “hysterectomy” from medical vocabulary, to be replaced with “uterectomy," which
simply means removal of the uterus. Their justification is that though the word hysterectomy is related to the Greek word for uterus, hysterus , the term uterectomy
conveys none of the centuries of sexist beliefs that claimed that the uterus was the seat of female "hysteria.” [18]
The relationship between hormones and the voice has been known since the 8th and 9th centuries, but only as it affected male vocal development. It wasn’t until
the 1940s that the effect of hormones on the female voice was considered in scholarly articles. There was little understanding about the evolving stages of the
female voice through the entire lifespan, or how our hormones, emotional health, and physical health are interdependent: each impacts the others. Relatively few
studies have been done on singing and the female voice through midlife, as compared to all other voice studies on men and women in other life stages.
P ROGRESS IN O UR U NDERSTANDING
Now that we are beginning to understand and respect what women are experiencing, it is clear that the changes aren’t “all in our heads.” There are real biological and
physiological processes happening to our bodies, minds, and voices, causing them to evolve. The more we know, the more we can help ourselves and each other.
The three of us together bring over 100 years of experience as vocal pedagogues, voice teachers, vocologists, and professional singers. We have taught every
level of singer from ages 4 - 93. We’ve worked with thousands of singers. Yet, in writing this book, we each discovered things about ourselves that we didn’t know,
and had revelations about our own vocal journeys.
For the first time, here is a resource for female singers that addresses issues they, specifically, may face as a result of menopause. It is the book we wish we’d
had 20 years ago. We hope it helps women everywhere realize that they are not alone during this time of change, and that it provides guidance toward strategies that
work best for them, if and when they are needed. We hope, also, that it offers insight to those for whom the journey is yet to begin.
It has been a gift for us to write it.
Chapter 1

EMPOWERING WOMEN WHO SING

A piano is a piano, and a violin is a violin. A voice is a person.
Peter Pears, British Singer
This book is about and for women who love to sing. It’s written for singers who are approaching, moving through, or beyond times of fundamental changes in their
bodies: the menopausal transition and aging. At long last, information about menopause and its long first phase, perimenopause, is being gathered and openly
discussed. It seems that every few days, another feature about the many signs and symptoms of this phase of a woman’s life shows up online and in news reports.
However, these sources rarely mention that voice changes, subtle or obvious, might be part of the menopausal transition. For those who notice singing voice
changes, starting even in the early 40s, confusion and discouragement are common. Some of us may doubt our skills as singers or may even think there is something
wrong with our voice. Those who are career singers may worry about the ability to pay the bills or to get hired. Even if we were able to find research addressing the
effects of menopause on the voice, such articles rarely include where to go for help. More importantly, scientific articles don’t talk about the deep sadness we may
experience when singing becomes undependable and uncomfortable.
The changes don’t end with the onset of menopause. As hormone fluctuations settle down, voices might become more dependable but changed. Then we face the
challenges of getting to know our changed voices. We also begin to encounter the increasing effects of aging on the voice.
Numerous interviews with a diverse group of women provide the foundation for this book. The women are in various stages of menopause and present many of
the issues female singers can face. Some of them are going through the midlife menopausal transition, some are just past menopause, and some have moved well
beyond it. Some have not struggled with difficult voice changes. Many have. Some have voice changes that have more than one cause. Others experience more simple
issues.
Though the stories are not the goal of the book, they certainly led us to that goal: To help women understand their remarkable bodies and their remarkable
voices. The need to understand the stories led us to study the research in numerous disciplines. That research has allowed us to share with women an understanding
of just what can happen during this phase in life - the many ways menopause can affect women physically, emotionally, and cognitively. The stories are as different
as each individual, as different as each of us. Eventually all voices change over a lifetime. We discuss the ways many women have adjusted to and accepted this
natural inevitability and provide information on where and how to find professional help, if needed.
Above all, the stories and research dramatically illustrate how important it is for women to keep singing, in groups or as individuals. This may be a rough time of
hormonal fluctuation and imbalance which will eventually move to a time of a new balance and a new voice, a voice that, though different, is appreciated and valued.
S INGING I S M Y I DENTITY
For Leslie, now age 65, understanding and being able to predict the vocal changes she would experience in her 50s was nearly impossible. Leslie told us, “My mother
and grandmother said nothing to me about menopause, and I never saw them struggle. My singing friends and I talked, but it was mostly joking or sympathizing about
menopause. No one talked about the upheavals with our voices, and also, not really knowing who you were any more or how isolated you felt. For some reason I felt
like I needed to handle the changes alone.” This “needing to handle it alone” is something that many women unconsciously feel, sometimes out of shame,
embarrassment, or confusion.
Leslie has sung all her life, starting as a child in church choir, through her teen years when she played guitar and sang along with the radio, and as a young
woman when she sang classical early music and oratorio. In her mid-30s she completed her college degree in vocal performance. Through her midlife years she
developed a love of classical songs and musical theater. Her community welcomed her frequent recitals, and she often sang in church.
Leslie went through perimenopause and the beginning of midlife with no noticeable voice upset. But singing was challenging for several years when her periods
stopped at age 52. “My voice was unpredictable and unstable; it was terrifying.I wasn’t sure what was going to come out of my mouth. I kept thinking, ‘Everything in
my body is the same as the day before. My posture, my breathing, my core feels the same; but the sound and singing sensations are unexplainably different day to
day.’ I decided that I could no longer perform in public, but the choice filled me with grief. I prepared for what I thought would be my last performance – expecting
my voice to behave poorly. But it went much better than I expected, so I kept singing!”
Her voice challenges may have been partially from hormonal changes, but she also discovered a health issue. She had developed a case of silent reflux, which
means she didn’t feel heartburn. The reflux was affecting her vocal folds and contributed to the instability of her voice. The laryngologist (also known as an ENT – an
ear, nose, and throat doctor who specializes in care of the voice) who diagnosed her prescribed a reflux medication. She also began to exercise more, which bolstered
her respiratory system and core muscles, enhancing her singing skills. Her voice improved. “Singing is my identity, the way I communicate with others, my artistic
voice. I kept singing and my voice stabilized. It’s not my 35-year-old voice; it is something different.”
Leslie now performs frequently and keeps learning and practicing. With recent changes in her vocal regimen and further tweaks to her technique, she feels at 65
she is singing better than she has in years. “I’m more relaxed about performing these days. I’m not concerned about being perfect. I really don’t think about pleasing
or impressing my listeners. It’s about love now, and gratitude that I can still express myself through song. I am more concerned now with how I communicate and
share with an audience.”
S ORTING THROUGH V ARIABLES IN W OMEN’S V OICES
It was clear from our interviews that some singers sail through menopause feeling they are singing better and better. Even after recovering from times of illness or
surgeries they felt great about their singing. For others, disruptive voice changes are common, especially for singers, who are attuned to subtle changes. [19] As our
bodies change through midlife and aging, so do our voices.
So why do some women have very few vocal problems while others go through so much? The answer is often complicated, but factors can include how women
respond as individuals to hormone changes, physical changes from aging, voice health, overall health, and having access to treatment. Other considerations might
include a woman's stress level, emotional and cultural issues, as well as artistic expectations.
Margot, now 62, is a woman who had very few problems with her voice during menopause. She was a devoted life-long singer, but she stopped studying voice for
a long time because she was a stay-at-home mom for her seven children. She resumed voice lessons in her late-30s once her kids were older.
Margot entered menopause a little on the early side, at 45. She said that she didn’t grieve the loss of her fertility; in fact it simplified her life. “You know, I was
in the throes of managing a huge family. Not having to deal with my cycle was one less thing for me to worry about. There are many more women who suffer much
more than I did. You know, I’ve always been mindful that I need friends. We compared notes as we went through all this. It helped.” During perimenopause, Margot
was performing frequently, but didn’t notice any voice change.
However, not everything was going smoothly at that time. Margot remembered, “The most egregious, the most horrible change for me in my early 40s, while I
had four high schoolers at home: I could switch to rage in two seconds flat. I would find myself hair-on-fire screaming at someone. It was almost like an out-of-body
experience - like it wasn’t me! And that is not my personality. I have always been fairly laid-back, even with my big family. It scared me so much that I went to the
doctor and said, ‘I have to do something.’ I started hormone therapy. It was what I needed, because it helped me so that I didn’t have that short fuse. Several years
later, I found as I weaned myself off the hormones that I didn’t need them anymore. No more rage problems.”
As a post-60 singer, Margot says, “While I don’t think I sound ‘old,’ I don’t have the range that I once had. I’ve lost some notes off the top. I’ve always had a
low voice – I even sang tenor in high school if needed. So, I don’t have new low notes, but my lower voice is richer sounding. Flexibility is slower, but I can still keep
up in a choral situation. I work out regularly, and I think that helps the voice. I sing with more freedom, and I’m just more relaxed about it. I have to sing. To lose
my voice would be as devastating as losing eyesight or hearing. It’s who I am.”
Unfortunately, there is no way to predict who will face challenges; even famous singers can have vocal struggles. In 2018, folk singer/songwriter and social
activist, Joan Baez, at 76 years old, was on a performance tour. She talked about her vocal journey and training in an interview. “Here I was, about age 30, Miss
Natural Voice, who had to start taking voice lessons after I was well-known because things started not feeling right.” She went on to say that to prepare her voice for
the 2018 tour she saw a voice therapist while also making quite a few musical adjustments. She was also careful about her song choices. [20]
Each woman, like Joan Baez, has her own unique and oftentimes unpredictable vocal journey. Of all the overlapping factors that contribute to vocal changes over
the lifetime, the menopausal effects on singing voice may be one of the least understood. Voice researchers and voice pedagogues will likely concur with Dr. Kathy
Kessler Price that “Comparatively little research has examined female singing voices in various hormonal conditions”. [21]
The average age of menopause in industrialized countries is 51. [22] The most pronounced years of menopausal transition - the few years on either side of the end
of menstruation - often happen at the same time that the early aging process begins. Because of this, it can be very hard to tell which of the two is affecting the
voice more, hormones or early aging. The subtle effects of aging can overlap and compound typical menopausal voice changes.
Without question, other aspects of our lives also complicate the situation. Health problems, stress from challenges with our children, caring for aging parents, our
job and finances, the ups and downs of relationships and marriage, and even divorce can have an effect on our voices.
The women who shared their stories with us experienced all of this and more. By looking at their vocal lives through the lens of research, we can begin to
understand many of the contributing factors. We have sifted through the challenges these women faced and included the individual solutions that helped them. We
considered various issues separately, and also looked at cases where multiple issues may have contributed to vocal troubles.
L OOKING FOR THE C AUSE OF V OCAL C HALLENGES
Many of us who experience singing challenges don’t realize the problems could be from hormone changes or aging. Depending on the problem we are having, we may
tell ourselves we are not good singers or blame poor technique instead of looking to our constantly changing bodies as a possible source of the challenges. We may
also blame our frustrations on our surroundings, such as air conditioning, heating systems, or allergies.
This might have been the case for Samantha, who is 52 years old and a professional blues singer. Samantha is postmenopausal, physically fit, and taking hormone
therapy (often called HT). Even so, she still has trouble singing, especially during long sets at outdoor festivals in the summer. She experiences vocal instability and
throat dryness, which are common results of hormonal changes. Throat dryness makes her voice crack and can cause her to lose access to her blues “growl.” For a
lead singer, vocal unpredictability can hold back a career.
Before we talked, she had assumed it was the hot, dry air that was giving her trouble. But it’s also possible that her vocal issues are related to postmenopause,
and she could try to address them with her doctor. To get through, she’s been drinking lots of fluids with electrolytes and rests her voice between sets. The good
news is, Samantha told us, that as the years pass, “My voice is getting more stable, maybe even getting better.”
It can be complicated to figure out the causes of vocal troubles. Many of the factors we’ve already mentioned can impact us at the same time. Unfortunately,
unless seeing a voice specialist, women seeking help from the medical profession may find that most doctors are unaware that hormonal change can impact the
voice. The western medical world, in general, doesn’t know that the menopausal progression can cause changes in the speaking and singing voice. That leaves it up to
us as singers to keep seeking help - to keep asking until we get answers.
One tenacious woman we talked with has had a complicated intermingling of symptoms. Rivkah, at age 60, has been singing for most of her life. She also
teaches singers in musical theater, jazz, and a cappella styles. She entered menopause 15 years ago but is now encountering new and troubling voice issues. “My
voice started to change (or at least I noticed it) only in the last 2-3 years. I’m getting vocally tired much faster, my voice is lower, and it takes me longer to warm
it up. Six months ago I went to a laryngologist in a hospital to see why I’ve been losing my voice, and she said that it looks fine, that I’m probably just getting old…
Now I use smaller range songs and transpose everything to lower keys. I can’t use my head voice anymore, only chest voice and some mix. I have so much to
express through singing – theater songs, emotional songs, jazz. I have lists of songs that I want to perform that have words that represent something of me. I still
hope to have the courage to sing with a friend and find the songs that I can still sing. But it’s a great pain to live with so little voice.”
Rivkah also said that the deterioration of her voice in the past few years coincides with high blood pressure, high cholesterol, and low function of the thyroid
gland. “I exercise my voice every day; and sometimes I feel that my throat closes, and I want to cry.” Rivkah describes herself as “nice, loving, and competent” but
her mood swings have become worse over time.
An ideal team approach for Rivkah, which might be impossible for many of us who don’t have access to a team for geographical or financial reasons, would be to
see a laryngologist who understands the needs of singers, a speech-language pathologist who can help her speaking voice, and a singing voice rehabilitation specialist
for improving her singing and developing an ongoing singing plan. In addition, she might consider an endocrinologist to evaluate her thyroid function, as it can affect
the vocal folds; and a therapist to help her with life's cycles and phases. Rivkah has never given up on finding solutions. In a recent update, she told us she has
connected with an excellent voice teacher and is already having positive results.
Exploring and Collaborating
One of our goals is to help every woman understand she is not alone. Until recently, voice changes from menopause and aging have been almost unmentionable
topics. If a woman talked about her challenges, especially if she was a professional singer, it could have meant decreased opportunities and even the end of her
career. Most women have stayed silent, coping the best they can, assuming they have to deal with their baffling voice issues by themselves. That is not the case.
Millions of women around the world are on the same path, and we no longer need to walk that path alone. Working together gives us a better understanding of the
vocal issues women might face and how to minimize them.
The physical and spiritual benefits of singing, not just for singers, but for all people, are well documented. A touching example of the incredible power of singing
was told by Alfred Wolfsohn, a stretcher carrier at the front lines during World War I, who, after the war, suffered from what we now call post-traumatic stress
disorder. Wolfsohn used singing as part of his eventual recovery. He said that using his voice accessed “the muscle of the soul.” “When I speak of singing I do not
see it as an artistic exercise, but as a possibility and a means of recognizing oneself and of transforming this recognition into conscious life.” [23]
Another perspective comes from the Rohingya people of Myanmar. Singing is part of their culture. When many became unwilling refugees living in India, they
brought their singing traditions with them. One Rohingya, when asked why he sings, responded, “When I sing songs or play music, the soreness I have, the
unhappiness I have in my body, it goes away.” [24]
For Mary, a 50-year-old country singer, the journey to become a singer was part of a painful recovery. She told us that through singing she found the courage to
use her once-silenced voice to find her strength. She sang to begin a profound healing process after suffering unspeakable traumas. She was repeatedly sexually
abused as a child. When she began therapy in her mid-20s, she was advised to take singing lessons to learn to “voice.” “When I started to sing, I knew I had to sing
for my own sanity. There would come a point in my lessons when I would freeze up and realize I needed more therapy and time to understand that I was worth
working with.” Once she felt better, she could start lessons again. Singing helped her move through the deeply buried issues and continue her healing process. Her
progress became a measure of how far she had come. Now, twenty-five years into her vocal journey, Mary is starting the hormonal “change of life.” At the same
time, she has started recording in a studio.
Mary sings and takes voice lessons for her own healing and spiritual expression; but all of us, at any age, can share in the power of music. Singing keeps us
mentally sharp, physically active, and socially engaged. It may provide relief for stress or pent-up emotions, as well as being an avenue to creativity, fulfillment, self-
care, and community. Each of us has a life full of ups and downs, including aging. Yes, the journey may be difficult; but singing can be a navigational tool to steer us
through stormy waters. It may also simply make the trip more fun.
Those who wish to sing always find a song.
Swedish Proverb
Chapter 2

PERSIST IN SINGING
The way I see it, if you want the rainbow,
You gotta put up with the rain.

Dolly Parton, American Country Singer

The deep need to sing can persist for a lifetime, despite vocal challenges. Singing can help us express joy, struggles, gains, and losses. While our vocal tone and ease
in singing may change from hormonal shifts and aging, it is also true that singing may become fueled by new passions and interests. The women of this chapter
show how they persisted with singing, despite the challenges they faced along the way.

M ENOPAUSAL V OICE C HANGES

Our voices evolve throughout our entire lifespan. As our bodies and thoughts change, so do our voices. The hormone-driven transformation of the voice from
perimenopause to postmenopause takes place over time – up to 10 to 15 years – happening for most between the ages of 40 and 60.
Voice changes usually start as barely noticeable physical discomfort or changes in sound that seem to come and go. Some of the most common issues are dry
throat and mouth, decreased volume, reduced flexibility, and changes in pitch range. Sometimes we unconsciously try to overcome these gradual changes with small
muscular adjustments in order to compensate for what isn't functioning well. For instance, if a person injures her index finger, she will adapt how she writes; but the
adaption can cause different problems in the hand and wrist. Eventually these new vocal adaptations can lead to dysfunction and make things worse. Accepting vocal
changes and reexamining technique are two of the many ways we can keep singing well, similarly to how older athletes retrain to adapt to their older bodies. It helps,
though, if we have the information we need about our voices and the determination to move forward.
Millie, 52, is a great example of someone who found ways to adapt to her vocal challenges. She’s sung in gospel choirs her whole life, as did her mother, aunts,
and her four children. Once her children were grown, she embraced the empty nest by going back to school to finish nurse’s training which she’d put on hold for over
30 years.
Millie told us, “I had heard of perimenopause somewhere but don’t remember where. I certainly didn’t pay any attention to what it might mean for me personally
until I was in it. My periods stopped right before my 51 st birthday. My singing started to feel thin and strained about the same time, like it was washed out in color
and energy. I had to clear my throat more often and it felt drier. I was thirsty all of the time.” Millie told her doctor about the dryness and thirst and the doctor
wisely tested her for diabetes. Thirst and dry mouth are symptoms of diabetes as well as menopause. [25] Those tests came back negative. She also found she
couldn’t reach low notes as well as she used to and said her range started to shrink. “My choir director’s wife is a voice teacher, so I joined her group voice class.
The class helped me feel more confident and positive about having something to contribute to the choir. I learned about the importance of staying hydrated and how
it can affect the way the vocal folds work.” She called the group lessons “little vocal workouts.” “I sing because it lifts me up and helps me lift up others. It’s a
service to my God and my church. Music goes beyond words, and you have to be in that place to feel that there is more to the world than what we can see and
touch.”
When asked how she felt about her voice changes, Millie thought for a moment and said, “It bothered me a bit; but honestly, I didn’t have much time to think
about it with my busy family. After I stopped menstruating, I went on hormone therapy. That helped with my mood, and it reduced my hot flashes. At the time, three
of my four children were still at home; and until the HT, they got on my last nerve. I felt like I could be more myself on the hormones, make better decisions, and
do more for myself.” Millie made adaptations that allowed her to enjoy singing and to stay in her choir.
T HE B ENEFITS OF L IFELONG S INGING
Some women feel, for long stretches of time, that they don’t want to sing anymore. There are many reasons why a woman might lose her joy for singing. For some,
everyday life can be overwhelming and stressful, leaving nothing for singing. Others face such serious physical challenges while singing that the hurdles seem
insurmountable. And some are held back by self-consciousness because they worry about what they might have lost vocally, how people will perceive them, or even if
they’re able to sing in tune.
Can joy in singing be rekindled? Are there reasons why we'd even bother? As we consider these questions, also consider this story: a soldier trapped in a bomb
crater during World War I carved the following message in the rock wall, “Canta che ti passa.” Sing until it passes. It is a heartfelt invitation to shore up courage and
take the mind to a better place.
Despite how we might feel about singing during certain stages of life, finding ways to continue singing can be very important. Singing activates the parts of our
brain dedicated to movement, hearing, memory, language, planning, organization, and emotion. [26] Some researchers suggest that even humming may have a role in
sinus health. Singing induces a calm brain-wave pattern. No wonder “Ohmmm” is used in meditation: it is a natural centering tool anchored in vocal vibration. [27]
Singing along with others is also beneficial. When we sing together our bodies respond in remarkable ways. Brain chemicals that promote well-being, like
serotonin, dopamine, and oxytocin (the love hormone), for example, are released. [28] Cortisol levels balance, and immunoglobulin IgA, one of the big players in our
immune system, rises. [29] When we sing together, breathing and heart rates begin to coordinate. Even brain waves begin to align among the singers. [30] Furthermore,
the benefits of singing for physical health, such as improving lung capacity, core strength, and vocal health, carry over into other aspects of our lives.
The unique tone quality of each of our voices is how others know us. Our voices can impact the world with meaning. Singing can be an act of self-care and even
an act of rebellion providing a channel for emotional expression that goes deeper than words. Because our voice is intimately linked with our identity, when it’s out of
order, even from just a cold, it feels like we aren’t all there.
In the stories we’ve heard, stress and overbooked lives were major reasons women took breaks from singing. Difficult divorces and development of
perimenopause symptoms often coincided. Deanne’s story tells us that if we keep singing, even if we don’t want to, it will pay off later. Now Deanne is an energetic
60-year-old grandmother. You’d never guess she came through formidable challenges to get to this point. She taught public school music for many years, raised three
children, and felt stable in the life she had built. But in her mid-40s everything fell apart: her marriage, her financial security, and her health.
Deanne experienced many typical perimenopausal symptoms in her 40s: mood swings, depression, hot flashes, severe anxiety, and heavy menstrual bleeding. At
the same time, Deanne received a diagnosis of a serious nerve disorder, and she became the sole supporter of her three children. Psychosocial stressors as well as
illness may have had an effect on the severity of her menopausal symptoms. [31]
Voice changes due to menopause might have been the least of her concerns. Nonetheless, as a school music teacher, a job that required her to keep singing, she
noticed changes in her lower range and annoying dryness of her vocal folds. She worked with a voice teacher to reinforce efficient singing habits. Deanne credits the
fact that she never stopped singing for her otherwise easy voice transition through those years. Although she feels her voice is a bit thinner now and she has lost a
few notes in her upper range, she never lost conditioning.
Deanne eventually became symptom-free of the nerve disorder, which she attributes to working with a naturopath, healthy eating, taking supplements, adding
body and balance work, and building a positive attitude. Now well into menopause, she has remarried, retired from her school music job, and teaches others to sing in
one-to-one lessons. She sings in three small combos and sings solo as well. “My voice feels even better now that I’ve retired. I am less stressed. How you feel is
related to your ability to sing. I really enjoy the kind of singing I do now, but I have to take breaths a little more often.” Deanne’s latest singing experience is in a
hospice music group where families and their departing loved ones are supported as the musicians play and sing.
We learn from Deanne's story about what can happen when a person has to sing even if she doesn’t always want to. Sticking with it can pay off later. At its
most basic level, the voice is a part of the human machine of nerves and muscles. If we let the singing voice go silent for an extended time, we risk disappointment
when we try to recover it later.

S ORTING O UT C OMPLEX S ITUATIONS

“I am a walking piece of work right now,” joked Sharon, age 58. Sharon is a life-long classical singer who refers to her life as “one big song list.” She was a theater
major in college, sang with the professional chorus of a major symphony, and has worked in musical theater. Sharon recently entered menopause which, at 58, is later
than the average age of 51. In her case, sorting out menopausal symptoms and her health history is complicated. “My speaking voice sounded like I had a cold for
over two years. Then I did a musical, and during the run of the show I developed a pattern of doing a single show, losing my voice for a day, doing the next
performance, losing my voice, doing another, getting sick and losing my voice…all over a five-and-a-half-week period. My mid-range used to be the best part of my
voice, but then it became weak. I despaired - why can’t I do what I used to do? My voice teacher recommended I go to an ENT. ”
Fortunately, Sharon found an ENT (otolaryngologist) who diagnosed silent reflux. Reflux is a condition in which stomach acid flows the wrong direction from the
esophagus; to the larynx (the voice box), the back of the throat, and sometimes even into the nasal passages. Reflux inflames and irritates tissues found in these
areas and prevents the vocal folds from functioning well. Sharon’s vocal folds were in rough shape so she started medication to calm the reflux down. Her ENT also
found a slight head tremor and found that her right and left vocal folds were sometimes out of sync. These conditions, which were not related to menopause or
reflux, can lead to huskiness or roughness in the sound. She worked with a speech therapist to help improve the health of her voice through better speaking habits.
She was also diagnosed with sleep apnea. One bonus from the sleep apnea treatment is that her throat doesn’t feel as dry as it used to, since she gets humidity
from her CPAP machine. [32] Then she went back to her singing teacher who helped her with her singing voice. Sharon regained her upper range and is delighted she
can sing higher than ever before. Her middle voice has also gotten stronger.
When things were at their worst Sharon said, “I felt that both my voice and my body were abandoning me.” Happily, things got better. Part of her journey has
been putting herself first. “I just don’t worry about taking care of everyone else before me. I warned my husband and my teenage son that I’m not gonna do it all
anymore!” Sharon is philosophical about the challenges she faced. “They were temporary – good or bad, long or short. Things change. If you fight it, you end up stuck
in a mud puddle. Accept – but adapt!”
The more we understand the different symptoms of menopause and aging on the voice, the more aware we can be of how those symptoms differ from other
medical issues. Having that awareness can help us find the support and care we need and relieve us from some of the frustration and shame women have often felt
for far too long.
B EING O UR O WN W ORST C RITIC
A number of women interviewed spoke of gaining freedom for their singing as they passed through midlife. They said things like, “I care less about what people think
of my singing,” or “Perfectionism is a thing of the past. I feel like I have something to say and I just say it the best I can.” However, that wasn’t the case for Anna.
Anna's story made us wonder if her return to singing was made more complicated by her fear of being judged as an older singer.
Now 63, Anna experienced an early menopause at 43. “When I didn't have my period for a few months, I thought I was pregnant. But it turned out that my
reproductive system was dying which was quite a nasty shock.” She had many physical and emotional symptoms post menopause, including outbursts of rage and
night sweats. As a well-trained singer and voice teacher, she practiced daily and performed regularly before and after menopause. She was delighted that her voice
remained “nimble and quick” the whole time.
But when she was 57, she had to stop singing in her choir because of a new job. She didn’t sing at all for six years. Then out of the blue, she was recruited to
join her daughter’s choir. “When my daughter asked me to join the group, I was terrified! I didn’t know what I would sound like. All I knew was that everything about
my voice felt different.” Anna told us that when she was younger, she had judged older singers. “I would say, when I start to sound like that, somebody should give
me the hook, right?” Nonetheless, she decided to give the choir a try for her daughter’s sake. She took a couple of singing lessons which helped her see a new way to
approach her voice, and she began to practice regularly again.
After a while, her voice regained its agile quality and she reestablished a good top end. The big surprise was that her lower voice had grown in richness and color.
“It was an epiphany! I’m considering singing some torch songs – something that my younger voice could not have done.”
In truth, many of us struggle with being critical of others; sometimes we judge others quite harshly without understanding the whole story. Several women
admitted, like Anna, to having negative feelings when they were younger about older singers who struggled. Clearly being judgmental is not a healthy path to follow.
We need to gather all the knowledge we can about how the voice changes, apply that knowledge, and forgive ourselves for being critical in the past. Moving forward
requires compassion and understanding for ourselves and our fellow singers.
It is also worth considering that fear, whether or not we are aware of it, might compound singing problems. Because of the interplay between the emotional
centers of our brain and muscles of our voices, strong emotions - including fear - can impact our singing. Fear of being judged, fear of what we’ll sound like, or
simply frustration about having a voice that seems to be a stranger, can almost guarantee disappointment. Rather than letting fear stop us, we need to transform the
fear into understanding, acceptance, and finding a new path for a changing voice, just as Anna did.
S TRESS C AN A DD TO V OCAL I SSUES
Stress responses to external and internal threats, whether conscious or unconscious, show up in our bodies. We must develop tools to reduce those stresses. This
takes an investment of time to deliberately implement new habits and routines.
A powerful example of the effects of stress on the voice comes from Kit, a 49-year-old busy singer and mom. She has sung all her life, leads a choir at church,
and sings in a quartet and a chamber choir. She is in perimenopause with several typical physical signs including night sweats, skin creep, and heavy periods.

Skin Creep [33]

Skin creep is known in the medical world as formication. Formication is a symptom described as a sensation of
“bugs crawling” or “pins and needles” on the skin. The menopausal transition can cause changes to the skin, and is
one of several potential causes.

Kit found out about perimenopause from reading Dr. Christiane Northrup’s book, The Wisdom of Menopause. She shared that “For about two years I dealt with
some ego identifications that were no longer serving me but were very rough to let go of. I ran into situations over and over again where I didn’t feel valued or seen.
All these situations made me very sad and angry. I had to learn to go towards situations where I felt valued. And I had to learn to value myself first, not in an
egotistical way, but something deeper.”
In Kit’s case, her singing voice didn’t seem to be causing her any trouble, but her speaking voice was tense with the chaos she felt inside. Her singing trouble
started during a holiday season full of rehearsals and performances. Kit was singing first soprano in a concert with one of her choirs, and the other two first sopranos
were out sick. That left Kit as the only one in the section, but she was sick as well. Nonetheless, she decided “to take one for the team” and sang the concert as the
lone first soprano, even though her vocal folds were fragile from her cold.
“I wanted to be thought of as the person who saved the concert. That concert, plus the stress of my church job in December, plus losing my patience and yelling
at our teenager, were the perfect storm. All of a sudden, my speaking voice was raspy and kept cutting out on me. I felt throat pain and tightness.”
Kit consulted with an ENT who diagnosed a polyp; a tiny fluid-filled sac on her vocal folds. This was hard news to receive, since she “always preached vocal
health to her choir.” She told us, “It was like my voice said, I’m gonna show you, when I forced it in that concert.” Kit was put on long-term voice rest. The medical
prescription of total vocal rest means absolute and complete silence for a certain period of time. Her voice rest was followed by voice therapy and work with a
skilled singing teacher.
Her polyp is now gone, and she has resumed careful singing. As a result of therapy and voice lessons, she is much more aware of how the overall stress and
anxiety that she carried in her body was relayed to her voice. She told us that she learned from speech therapy that she had been speaking with a great deal of throat
and chest constriction. The first step was that she had to release the tension before creating new speaking habits. The tension seemed to be related to issues of
self-worth and her perception of needing to conform to the expectations of others. Enforced silence and the following recovery period helped her reconsider her
relationship to her voice. “Now that I am able to sing and speak again, I appreciate and baby my voice; and I am much more accepting of my voice. I realize it’s a
symbol of myself.”
Shortly before our conversation, Kit had a chance to practice her newfound appreciation for her voice. A substitute conductor at a rehearsal asked for more
volume from the first soprano part, and again, Kit was the only one singing that part. “This time I wasn’t going to do it. I chose to protect my voice and not push it.
In addition, I now use a microphone when I direct my own choir. When I’m asked to sing in styles that I have not studied I just lip-synch. I cannot force my voice to
be something that it is not or sing in a way that is unfamiliar.”
Kit added, “What came out of all of this is that I started to observe how our culture can make women feel that to be of value, they have to be all things to all
people all the time. We are taught to be the support, the one who nourishes: the everything. I became so tired of this role. I think things are getting better, but we
have such a long way to go.”
Although we all generally like to be persistent toward our goals, a dark side of “persistence” emerged from Kit and some of our other interviewees. It could be
called “pushing through,” especially when the voice is compromised due to sickness or to an unperceived, subtle condition of the vocal folds related to perimenopause.
Sometimes we carry symptoms of unhappiness or stress in our bodies, which show up in our voices.
S ELF- C ARE I NCLUDES S INGING
For the millions of women who are busy with careers and active families, perimenopause and its emotional, physical, and vocal changes can seem to sneak up on
them. Through persistence, we often keep going with our many commitments, chalking up any symptoms to fatigue or even health problems. All of the women we’ve
heard from in this chapter encountered growing awareness of changes during midlife, vocal as well as others. They educated themselves, adapted, and accepted. And
along the way, they refined themselves into something better and stronger than before. Their persistence included developing compassion to care for themselves,
something we all must do. Moving through this ambiguous time takes patience and is a necessary process to health and well-being.
D EVELOPING G ROUNDED AND C OMPASSIONATE W AYS WITH Y OURSELF

There are many ways for you to be grounded and treat yourself with compassion. Here are a few ideas.

Make changes in health and wellness, from lifestyle choices, to nutrition, to a sane exercise routine

Take time for meditation and religious practices

Work with a spiritual counselor

Seek out medical professionals who will listen

Research on your own behalf

Connect with friends of a similar age

Drop unhelpful commitments

Let others take responsibility for themselves

Disentangle from dysfunction in relationships, including with loved ones

 Ask for help from those with the capacity to actually hear and help

Participate in the arts; dance, visual art, or music, as therapy and physical grounding.

Practice yoga, tai chi, qigong, and other mind-body practices

I T IS W ORTH I T TO P ERSIST
As we change, so do our hopes and dreams. What once was a passion for singing might have become indifference. Does that mean we can quit singing? Life changes
such as challenging health, moving to a new home, moving away from a choir, or other life restructuring events, can take away the opportunity for regular singing. We
may find ourselves helping kids and grandkids, taking care of elderly parents or a spouse with health challenges, all while trying to stay current in a career.
On top of that, society might tell us that old voices aren’t pleasing, that people shouldn’t sing after a certain age. Does that mean we can quit singing? No! It’s
very possible to sing well as we get older, but it takes practice, just like maintaining any other skill, such as playing an instrument or a sport. It might also mean
letting go of expectations for how you should sound or finding a new or different outlet for your singing.
Resist the urge to quit. Keep singing to maintain the best condition possible, recognizing that this phase may last a while. That way your voice will be ready for
you when things settle down. Like Anna said, “It’s a use it or lose it deal.”
The voice is our most exquisite messenger of emotion. [34]
Dr. Robert Sataloff, Laryngologist
Chapter 3

HORMONE RELATED MIDLIFE VOICE CHANGES

...and my voice teacher Judi would say, “I would encourage you not to think of your voice as diminished. It’s just different.” Like, I think maybe I have a vintage
Ferrari on my hands, and I just don’t know how to drive it. [35]
Kathy Mattea, American Country and Bluegrass Singer
Will everyone with female hormones have voice trouble through midlife? No, many report noticing no vocal trouble, even though hormone changes are happening. In
some cases, developments are so gradual that the singer can adjust easily over time, and might even report positive developments, including improved richness of
sound.
Others might get a shock during our 40s or 50s: our voices stop doing what they did for the last 20-30 years. They become unpredictable and perhaps unfamiliar.
If this has happened to you, it’s not your imagination; you haven’t suddenly become a bad singer. There are scientifically verified hormonal reasons why this might be
happening. Even experienced singers who’ve kept up with technical training can be blindsided by the changes. They can happen to anyone. Every woman experiences
these changes in her own, unique way.
So, what’s going on? Why do some women have problems while others skate through? It has to do with hormone levels that are shifting and adjusting as the
body moves toward menopause. Hormones are produced by the endocrine system. They are like messengers that travel between cells, mediating our body’s complex
activities. According to the Hormone Health Network, “The female sex hormones, estrogen and progesterone, are most well-known because of their influence on a
woman’s reproductive health, from menstruation to pregnancy to menopause and more. But the body also makes and uses many other kinds of hormones that affect
other aspects of health - from energy level, to weight, mood and much more.”
The key players for voice are estrogen, progesterone, and androgens (testosterone). These reproductive hormones affect a lot more than reproductive organs.
Cells all over the body have estrogen receptors, including in the vocal folds, the brain, the immune and cardiovascular systems, tiny structures in the ear, muscles,
bones, ligaments, tendons, and elsewhere. As our bodies respond to the hormone fluctuations of the menopausal transition and the rebalancing of hormones with
aging, it’s no wonder that we are impacted in so many ways, including vocally.
W HAT A RE P ERIMENOPAUSE AND M ENOPAUSE?
Before we get into the details of what hormone reconfiguration means for our voices, we need a clear understanding of the common medical terminology used to
discuss this time in a woman’s life. Perimenopause is menopause’s “opening act.” Perimenopause is the word for the years when the reproductive system is moving
toward cessation of fertility. On the other hand, menopause is the time after menstruation ends. (Many women say that they are “in menopause” when they may
instead be in perimenopause.) Keep in mind that these are scientific terms, and may or may not have any meaning in other healing modalities, philosophies, and ways
of life. However, knowing the difference between perimenopause and menopause will help in understanding the conversations around this inevitable midlife passage.
For most, perimenopause occurs for several years before menopause. In fact, according to the Cleveland Clinic, women can enter this stage of hormone
readjustment eight to ten years ahead of menopause. [36] Typically, natural menopause can take place any time from the early 40s through the late 50s. The average
age is 51.
So how does a woman know she is perimenopausal? Not all women, but some may be able to predict when they are likely to go through it by knowing when their
mother experienced perimenopause and menopause. Other than that, unfortunately, hormone testing isn’t reliable; it is just a snapshot of a moment in time during
which our hormones fluctuate unpredictably. Hormonal contraceptives, such as progestin-containing IUDs and birth control pills, can mask symptoms of
perimenopause, adding to the difficulty of identifying the causes and effects of hormone challenge. [37] , [38] For most of us, we won’t know we are in perimenopause
unless we learn to pay attention to our bodies and emotions, start recognizing symptoms, and begin connecting the dots.
The list of perimenopausal and postmenopausal symptoms (some sources list over 30) can be overwhelming, especially for people who thought reproductive
hormones have only to do with reproduction. As a matter of fact, estrogen, progesterone, and androgens have receptors all over the body. As mentioned earlier,
estrogen has effects on the brain, the cardiovascular system, the immune system, bones, muscles, nerves, connective tissue, and more. When regular cycles of rising
and falling estrogen and progesterone become irregular, some women react with a variety of symptoms throughout their bodies. [39] Further changes may emerge
after a woman’s last menstrual period, when estrogen and progesterone levels plummet. For those who experience symptoms, it may be reassuring to know that the
reactions are due to changing and rebalancing hormones. Regular check-ups with medical caregivers should help sort out health issues that may have similar
symptoms to perimenopause and menopause.
P ERIMENOPAUSAL AND M ENOPAUSAL S YMPTOMS
[40]
The following symptoms, and many more, can happen during perimenopause and postmenopause. Some symptoms are:
hot flashes
fluctuating flow and timing of menstrual cycles
headaches/migraines
all-over dryness including the throat and the vagina
flashes of anger
sleep disturbances
foggy thinking
incontinence and bladder pain
joint pain and body aches

The next threshold, the period of time that follows the last menstrual period and ends 12 months later, can be bewildering since women don’t know that they’ve
reached menopause until a full year after the key indicator occurs: the final menstrual period. In medical terms, it’s a definite point in time for those who have been
able to enter menopause naturally and have kept track of their cycles. So, it’s a good idea for women to track their menstruation while their periods are irregular so
that they will know when the full year of no menstruation has passed.
For singers, the time after the last period may bring increased vocal issues. The last period signifies a strong drop-off of estrogen, which may be a source of
relatively sudden voice change. Elliott’s survey showed that 48% of the respondents had troublesome voice changes within a year following the end of menstruation.
[41]

In some cases, medical reasons cause women to go into menopause. If a woman has had both of her ovaries removed, she is immediately in induced
menopause, which is a major and sudden shock to her system. Women going through treatment for cancer may have irregular periods or may stop having periods
temporarily or permanently because of the treatments. They may suddenly experience menopausal symptoms.
H OW O FTEN D O O UR V OICES C HANGE?
Our voices change throughout our whole lives, from infancy through our later years. Some of the things our voice responds to are:
Growth hormones when we are young
Pregnancy, breastfeeding, and monthly menstrual hormone
fluctuations throughout our reproductive years
Quantity and quality of lifelong voice use (wear and tear)
Lifestyle, health, and wellness choices
Some medications
Underlying health conditions
Conscious and unconscious inner attitudes and beliefs
General aging

There are two points in our life cycles as women when our voices change fairly dramatically: puberty and moving through midlife hormonal changes. We might
consider these later changes to be a mirror image of adolescent puberty and possibly a second voice change.
H OW H ORMONAL C HANGES I MPACT THE S INGING V OICE
After puberty, female bodies secrete levels of androgens (testosterone) throughout their lives, though in much lower levels than male bodies. In most women, before
perimenopause, estrogen balances the effects of androgens. Estrogen levels begin to fluctuate during perimenopause, and after menopause they fall to a much lower
level. Therefore, the balancing effect on androgens is lost, which is why women may experience increased facial hair and acne, and changes to the structures of the
vocal folds. They may also have a general lowering of the voice or acquire more low notes. Some singers feel decreased ease and comfort in their upper range during
and after the menopausal transition.
Elizabeth, age 57, told us that she noticed her speaking voice was lowering over the years but didn’t think much about it. “It never occurred to me that the voice
can change along with everything else, and that there were things I could do to help keep it in shape. Growing up I studied voice privately and was active in theater. I
decided to stop performing at age 23 to pursue advanced business degrees to work in higher education and become a role model for young women.”
Elizabeth eventually gave birth to twins. Seven years later, she had ongoing profuse vaginal bleeding due to benign uterine fibroids, so at age 37 she had a
hysterectomy. She was able to keep her ovaries but was no longer having periods. After two years she began experiencing hot flashes and insomnia. To help get her
life back on track she took bioidentical hormones, [42] which reduced her symptoms and increased her libido. She noticed that her singing voice was lowering
considerably starting at about age 47. She adjusted by singing the tenor line in church hymns and switching octaves for tunes she sang in the shower.
Many people aren’t aware of the powerful role hormones play in a multitude of body functions. Not only do they impact us physically, they also impact our
emotions and sexual responsiveness. Elizabeth pointed out that, culturally, “many of us look toward midlife hormone changes as a sort of a panicked joke, presented
as something to be fearful or anxious about; but rather than being something negative, some women view the changes as something to observe and be aware of.”
Like Elizabeth, some believe a higher power, or possibly evolution, has designed the human body to go through passages and changes.
T IES B ETWEEN H ORMONES AND THE V OICE
As long as females have sung, some have probably sensed subtle changes to their voices related to their monthly cycle, pregnancy, and breastfeeding, as well as
during the menopausal transition. In fact, long before the scientific evidence was available, many European opera houses excused some female singers from
performing in the days just before menstruation and in the first days of their periods. [43]
However, modern medical professionals were not always sympathetic to singers’ complaints, including Dr. Jean Abitbol, a French laryngologist. When high-voiced
operatic sopranos complained of difficulties singing at the time near their periods, he responded with a “classic patriarchal medical response that it was ‘all in their
heads.’” [44] But his wife at that time, Dr. Beatrice Abitbol, a gynecologist, urged him to reconsider his viewpoint. They collaborated on a joint study in which they
examined cells from the vocal folds and the cervix of singers at different stages of the menstrual cycle. When they compared the microscopic changes of the cells
side by side, they could not tell which were the cervical cells and which were the vocal fold cells. The ground-breaking study proved that the vocal folds are a
sensitive receptor of reproductive hormones.
From then on, female singers were validated through scientific research when their voices felt “off” in the few days before their menstrual periods. In addition,
further studies have shown how hormone fluctuations affect a number of characteristics of the vocal folds and the precision of laryngeal function in singing. Following
his studies on premenstrual voice changes, Dr. Abitbol did further research on 100 female singers who were postmenopause, and identified voice changes including
loss of high range and vocal color, decreased agility, and voice fatigue. [45]
What does this mean for women whose reproductive cycles are waning or finished? It means that over the years when estrogen and progesterone production
from the ovaries lessens and eventually stops, women are in a state of hormonal flux. It could be said that perimenopause is like finding yourself in an obstacle
course without knowing where it started or where it will end. For those who have had a hysterectomy and are unable to monitor the behavior and timing of their
periods, it’s particularly challenging to assess where they are in the process.
 One of the women we interviewed, Uli, is a 63 year-old singer who knew changes to her voice might happen. So when they did, she did not take it personally.
“Every sports person, after the age of 25, knows that their muscles change,” she offered. “But the youthfulness of my voice was what captivated my audience when I
was a young professional, not exceptional technique.” Other women we interviewed talked about their younger voices, from high school or college, as if that voice was
an accurate measure of how they should be singing during midlife. As Uli pointed out, considering that no one expects to play a sport in their 40s and beyond the
same way they did when they were younger, we also shouldn’t expect our voices to be the same as we age, regardless of natural talent and physical condition.
Even though Uli was one of those singers who had early rigorous training and years of fulfilling performing, there came a point when she had to approach her
singing in a different way. “I reached the age of 50 and had managed to learn how to sing a really beautiful pianissimo (soft singing with substance in the sound), but
I didn’t have the breath to make it through a phrase, so a fat lot of good that pianissimo did me!”
“Ten years after menopause, when it felt like the last little gram of estrogen left me, I noticed my voice had changed.” She has never taken HT because she
believes in the natural healing of the body. She also knows that most musicians, not just singers, may need to work a great deal harder and make adjustments as
they get older.
However, she’s lost the motivation to practice, because she “wouldn’t want to sing and sound awful.” She reports a less sharp memory and reduced ability to
easily learn new things, which irks her. She is afraid of not remembering words or music in performance. But she has found ways to move forward. Uli is more
interested in group music-making now and loves teaching singing, which gives her the daily workout her voice continues to need. She sings chamber music with
instrumentalists where she can use sheet music. She is also exploring different ways to express text.
As we have discussed, science has established that the larynx is a target of sex hormones. Understanding some of the effects of these on the vocal mechanism
after puberty helps us understand the changes that may accompany perimenopause and menopause.

H OW R EPRODUCTIVE H ORMONES A FFECT THE V OICE [46]

Estrogen is a major player, vocally speaking, because it:

causes suppleness of the vocal folds’ upper surface (the mucosal layer)

supports the glands that produce the thin mucus that coats the surface of the vocal folds

maintains tone and bulk of skeletal muscles, including the deepest layer of the vocal folds, which produce lower pitches, and the tiny muscles that produce
higher pitches

blocks the effects of androgens (testosterone), preventing lowering and thickening of the voice

increases oxygenation to the folds by improving permeability of the blood vessels and capillaries
Progesterone is another key player, because it:

encourages the surface of the mucous membrane of the folds to slough off

causes decreased and thickened secretions of the outer layer of the vocal folds, resulting in drier vocal folds

decreases permeability of the fold capillaries, leading to swollen vocal folds

may be involved in neuromuscular activity, supporting quick responsiveness of the laryngeal muscles

balances effects of estrogen throughout the body

Androgens, naturally secreted in women’s bodies can:

cause the vocal folds to thicken, which lowers pitch

increase dryness of the vocal folds due to changes in the glands that secrete fluids near the vocal folds

As perimenopause begins, hormone cycles we are accustomed to become less predictable. Levels of estrogen and progesterone may swing wildly, which is why
periods become irregular, light, or heavy - so heavy for some women that it’s called flooding. Flooding and heavy periods don’t affect the voice directly but can mean
immense distress and a need for lifestyle changes that can impact a woman’s work or performances.

Flooding (Menorrhagia or Hypermenorrhea) [47]

Unusually heavy bleeding, or flooding, during menstrual periods is experienced by 25% of women during
perimenopause. It is associated with an imbalance of estrogen and progesterone, irregular ovulation, and benign
fibroid tumors. In some women, the bleeding may be so heavy that they experience dizziness or even anemia. It can
be difficult to find solutions to overflowing tampons and pads, which for women who perform and present in public
is an added source of stress. Women who experience heavy bleeding should see their gynecologist or other medical
caregiver. Though it’s tempting to assume it’s just due to perimenopause, there are other possible causes that
should be ruled out. Caregivers may be able to suggest pharmaceutical or other solutions until periods naturally
space out and become lighter in late perimenopause.
 As for the voice and the condition of the vocal folds, fluctuations in swelling, suppleness, and lubrication may change rapidly as hormone levels shift irregularly.
These changing conditions may lead to inconsistent singing. Over time, as estrogen lowers, its positive effects on the voice decrease, leading to a thinner mucous
membrane and loss of elasticity and pliability of the supporting layers of tissue underneath the mucous membrane. If progesterone becomes the dominant hormone
the vocal folds may swell a bit and the secreted mucus becomes thicker and less slippery. Singers are very sensitive to the loss of flexibility and responsiveness of
these fine tissues, as well as sensitivity to conditions which can change from day to day.
How many singers notice changes? It’s difficult to say; studies vary. One source reports that 20-30% of the women studied report issues, [48] but in a self-
reported survey done by Martha Elliott in 2014, there was a much higher level of complaints, averaging at least 50%. [49] Though there is still plenty of statistical
room for the fortunate singers who sail through the hormonal storm with ease, it is likely that a woman who is very sensitive to her vocal instrument will notice at
least some changes.
W HAT V OCAL S YMPTOMS H AVE B EEN R EPORTED?
Symptoms reported in Elliott’s study included loss of notes in the upper range, decreased agility, changes in tone color, loss of power, stiffness, slowed vibrato,
difficulty with tuning, difficulties with both high and low range transitions, cracking, dry throat, and raspiness. In a study by Barbara Fox DeMaio, a few indicated that
their lower voices became problematic. [50] On the other hand, some reported that they benefited from a stronger and fuller low range.
It’s fascinating that there are many more varied responses to perimenopause and menopause than the information available to us ever brings up or highlights.
The following story told by Darlene, illustrates the variety of potential symptoms that just one woman can experience.
“I always knew I had a nice voice, and sang duets with my sister growing up,” Darlene said. “I studied singing privately with several fine performers who were
teaching in colleges and sang in community choirs and opera choruses.” Eventually, Darlene stopped singing completely to raise her children and build a career in
mental health. At age 37 she was invited to be a lay cantor at her synagogue; and in her mid-40s, she started studying jazz in weekly workshops.
“At age 44, I started noticing vocal problems after a bad case of laryngitis. I ignored vocal rest and pushed my speaking voice while attending a professional
conference. When I went to rehearse for the High Holy Days (special worship services) it was like my voice would "catch" and wouldn't want to start. There was also
a real loss of agility; I used to be able to easily sing the melismas found in cantorial singing.”
Darlene went to a laryngologist, recommended by other singers in her area, who said her vocal folds were fine. However, he did not give the type of exam, such
as using videostroboscopy, which is necessary to be able to see the tiny movements involved in vocal fold function while singing. Since nothing was found, Darlene
blamed herself. “I became quite embarrassed and anxious and had a great sense of loss. I was wracked with guilt for pushing my speaking at that conference.”
At age 57, after her children were grown and her private practice was manageable, Darlene began studying singing again. She performed in weekly jazz master
classes and workshops but was still having issues with starting her tone. Her voice teacher at the time suggested she might have reflux; however she was already on
reflux medication due to a digestive issue. She went back to the same ENT practice and is disappointed that the ENT and his speech therapist didn’t bring up the
effects of menopause on the voice. The medical community simply wasn’t aware of it at that time around 2009. To this day, while some doctors have become aware
of hormonal influence on the voice, much of the medical community still does not know about the connection.
The overall postmenopause and aging symptoms that remain now for Darlene, at 62, are some loss of mental clarity and acuity, and skin elasticity; “The flesh
just hangs off my bones now.” She started working with a voice teacher who is also a singing voice specialist. They are focusing on functional study and exploration
of body awareness, vocal health, mental focus, and belief systems. “We work slowly and deliberately. I’ve found it’s possible to sing better than what I had resigned
myself to! It takes relearning, retraining, and effort. But I had more joy and less anxiety singing through the High Holy Days services last year than I had experienced
for a long time and had real strategies for my solo work. Who knew?”
A DVOCATING FOR Y OURSELF
Why are voice changes so rarely included in resources about menopause? Considering that there are an estimated 43 million adult choral singers in the U.S. alone, [51]
more than half of whom we can safely assume are women, as well as millions more singers worldwide and many other musical genres, it’s about time that women
heard that they may experience midlife voice changes.
Because of this lack of awareness, some medical experts may chalk up voice complaints from middle-aged women to simple aging. However, it is likely more
complicated; hormonal effects on the voice can overlap aspects of vocal aging. Medical problems can make it harder to discern which symptoms are menopausal and
which are the result of other health concerns.
Studies and research are important, and more need to be done; but it is a slow process. As one speech therapist observed, “When scientific or medical studies
are conducted, the results are statistical averages and don’t relate individual experiences and stories.” This is why learning about the wide range of women's individual
experiences will complement what research studies have found.
Martha Elliott's study confirmed that when female singers who are confident of their skills mysteriously encounter frustrating voice changes, seemingly out of
nowhere, their response is often to doubt their own ability or technique. Emotional responses include sadness, grief, shame, and a loss of their sense of self. [52] Some
music industry professionals, performers, and voice teachers blame the singers themselves, assuming a lack of discipline, poor life-style choices, or inadequate voice
training. Yes, these things can affect the voice, but they aren’t the whole picture.
We must be open to becoming different singers through our changes, during which every part of our body is affected, from our fingernails to our intestines.
Anecdotally and personally, we’ve learned that there can be a fulfilling and sometimes hidden truth to uncover in our vocal lives as we move through the years of
perimenopause, postmenopause, and aging. That truth may include releasing the need to meet the expectations of others, interest in exploring newly enhanced
characteristics of the voice, and discovery of an overriding desire to impact others with our story through singing. When we go through the menopausal
transformation and “second voice change,” we each react to and create our own unique physical, emotional, and spiritual journey.
As a ship on the ways of the sea of life, the voice will travel through the wind of hormones and emotions. The voyage I propose to you follows the voice's changes
through the voyage of the hormonal storm of our being - its paths, challenges and limitations, and emotional impact. [53]
Dr. Jean Abitbol, Laryngologist
Chapter 4

SMOOTH SAILING
It’s your body. It’s your emotional life, your mind. We can’t divorce ourselves from our instruments.
Renée Fleming, American Opera Singer
Singing better and better through midlife is not only possible, it’s something many women enjoy. In fact, there are many women who experience very few physical,
emotional, or vocal challenges through this time. Perimenopause and menopause do not inevitably lead to horrible symptoms or insolvable vocal issues. Even if a
woman does have health issues or moderate to severe menopausal symptoms, her voice might not be affected. Several of our actively singing interviewees say that
they have never felt better about their voices.
This chapter is dedicated to the stories of some of these women. We looked for things they might have in common, clues that would benefit others. We did find
commonalities; but we also found drastic differences in things such as musical genre, quantity of voice use, technique, attitude, genetics, beliefs, and lifestyle.
K EEP AN O PEN M IND – W AIT AND S EE
Grace is a 54-year old woman who is still in perimenopause. She began as a jazz instrumentalist and for many years sang jazz and occasional musical theater songs
without a singing teacher. Her professional singing career took off in her 20s, when she started singing in clubs and working as a session singer and commercial jingle
artist. However, when she was in her 30s, Grace began to find singing to be an effort; she was losing her voice after singing for less than an hour in her club gigs.
She saw a voice doctor who diagnosed vocal fold nodules. Nodules are tiny areas of swelling on the edges of the vocal folds. They are associated with overuse of the
voice or poor vocal habits. Grace worked with a speech therapist to learn better speaking habits and establish vocal health awareness.
From that experience, she learned two hard-won lessons. Grace said, “I had been overtaxing the “golden goose” – my voice – because as a self-employed
musician I felt that I had to say yes to every possible job offer.” With better habits and wiser pacing of her performances and session work, her speaking and singing
improved. Also, Grace had been told by a concerned friend who worked with singers that her posture needed to be better when she was singing. She took that advice
seriously. Over an 18-month period she carefully rebalanced her body alignment and found more vocal freedom and resilience.
Eventually Grace suspected she had entered perimenopause; “Right now, I assume I’m in perimenopause but my voice is the most robust it’s been in my whole
career. I sing six to seven hours during my days in the recording studio, covering all kinds of styles. I do backups for other artists, jingles, movie soundtracks,
character voices, and voice-overs. I manage well with live gigs. As a younger singer, I never thought I’d have a thriving career into my 50s.”
Grace practices effective vocal care, such as hydration, steaming, and doing regular, simple vocal exercises. Her lifestyle includes prioritizing sleep. She bases her
eating on the Mediterranean diet and enjoys moderation in all things.
“Based on the rumor mill about other singers running into trouble with hormone changes, I was pretty worried, but I wish I hadn’t been. Women should wait and
see; they shouldn’t expect the worst. My mom had an easy go of it - good vocal genes! At 75, she is still a very active singer. She sings 200 gigs a year and never
gets vocally tired! I am so grateful to have her genes!”
Grace’s story has good lessons for all of us. Working to develop a solid and flexible technique that keeps the voice in shape can make a very big difference in
wear and tear on the voice. She also shows us the importance of taking good care of the voice, including drinking plenty of fluids, eating a healthy diet, and getting
adequate sleep.
U NFOLD IN THE M OMENT
When we asked Maria, age 60, why she sings, she said, smiling, “I sing because God told me I had to.” But she had to find her way as a self-taught singer. She grew
up in an underprivileged home in a small town where she and her four siblings filled the house with lots of live music-making. Eventually Maria took the stage as a
rhythm and blues singer in a club. Then she started singing radio jingles and doing voiceover work as well as performing and recording.
At 45 she went through a vocal rough patch. “I was recording a jingle, and for some reason, it felt like I had developed a hole in my voice. I couldn’t get the
sound to go through.” For the first time in Maria’s career, she started taking lessons with a voice teacher at a local college, who sent her to a laryngologist. The
doctor found no problems with her vocal folds, so she continued her work with her voice teacher. They worked on adding clarity to her tone and making sure that
Maria accessed her high range regularly. Eventually things smoothed out. Currently she works as an R&B singer, frequently sings standards from the Great American
Songbook, and is actively studying jazz improvisation.
 Maria reached menopause at age 50 or 51. She remembers hot flashes, irregular periods, and being bothered by a dry throat; but she assumed the dry throat was
because she was touring a lot and spending time in dry airplanes and hotels. Now, well into menopause, Maria says, “With age, my voice has never felt better. I’m
grateful I am able to sing. I do feel the best at the low end of my range—the middle range is harder. I work my high voice a lot because I know that it helps the rest
of my range.” She performs at least once a week, works frequently on recording projects, and teaches and coaches at a local school of music.
As we talked with Maria, it was clear that she cultivates a positive attitude and takes exceptional care of herself. Since she was quite young, she has had an
innate concern about what foods are best for her. Maria takes fish oil supplements and eats a diet rich in vegetables, salmon, and nuts. She eats no gluten and says
her diet helps with digestive problems. She practices yoga, receives regular bodywork, including Rolfing, myofascial release, and energy therapy. (Energy therapy is
based on working with the human body as a bio-energy field.)
Maria advises “Overall, choose joy; choose gratitude. Don’t take the bad stuff on board. And I believe in community; we need to help each other, build each other
up. As the years go by, I remember what Bonnie Raitt said, ‘I can be old and still sing the blues’. There is a concept in yoga that I like: unfold in the moment. I think
that more mature vocalists should apply that idea to their singing: own your voice as it is now.”
C ROSS T RAINING THE V OICE
Grace and Maria are both women who work in multiple genres, and they count it a blessing that they have not experienced new vocal issues during midlife. Aside
from their lifestyle choices, there are other ways we believe Grace and Maria are helping themselves. The key might be that they are singing in a variety of genres.
They are exercising the whole range of their voices, from low to high, on a regular basis, through what is known as vocal cross training.
Modern voice science has found links between athletic training for sports and voice-related training for singers. As Robert Edwin wrote in 2008, “Competitive
athletes are encouraged to participate in cross training activities that will exercise muscle groups differently than how they are normally used in their specific sport.
Football players dance, tennis players swim, golfers jog. Just as cross training promotes optimal performance levels and mitigates against injury in athletes, cross
training for the voice promotes similar results for voice athletes.” [54]
The cross training that Grace and Maria are doing includes:
Singing regularly in their whole range.
Exercising the voice specifically for strength and flexibility.
Healthily singing in more than one style or genre.

V OCAL F LEXIBILITY T HROUGH THE Y EARS

We were able to get a glimpse into the post-menopausal singing life of an elite Indian Sufi singer named Aditi. Aditi, 63, is an internationally known recording artist.
She told us she reached menopause at age 55. “My voice did not go through stress in any way, even when I went through a tremendous personal trauma a few years
ago. My pitch is the same, and I cover three octaves. I am also a very positive, spiritual, and confident woman; and I guess that is my major strength.”
The style of Indian classical singing Aditi performs is the devotional music of the Sufi. The vocal line is often full of quick ornamentation, or riffs, which could
have preserved her voice’s flexibility through the years. Aditi has also taught others to sing in a classical Indian tradition for many years. She has chosen to live a
“simple life, and is happy to travel like a tourist and not as a performer.” Her reasons for not currently performing have more to do with a long life spent in the public
eye than vocal decline. Aditi offered, “I have not been singing lately because I’ve lost interest in touring for concerts. I want a simple life now and do not want to
deal with jealousy because of my status.”
Aditi has had a fortunate vocal journey through midlife. It is true that there are best practices: choices we can make that might optimize our voices through
aging. However, such fortune can’t be expected for all women who have taken excellent care of their voices, minds, and bodies. There is no magic one size fits all
strategy; each individual journey for all of us will be a unique path.
C LASSICAL S INGING AND H EALTHY L IVING
Melanie, a light soprano, is a 66 year-old professional pianist and classical singer. She shared an opinion which is contrary to the experiences of Grace, Marie, and
Aditi. Melanie said that she feels “Classical singing only” is integral to why she is still singing well. “No belting, popular music, or other genres. I hate that stuff.”
Melanie points to her mother as an example of what she hopes to experience. “My mother is now 99,” offered Melanie, “and still sings for pleasure and sounds
lovely. I know that this is partly due to good genes and partly because of her healthy lifestyle and mindset.”
Over the past 10 years, Melanie’s relationship with her voice has developed into something deeply personal. “It’s not just technique. I love my voice. I have a
good relationship with my voice. I have no fear anymore about performing; there is no self-judgment. I know who I am; I know what my voice can do. When we sing
and perform, we connect and express how we feel deep inside. It is a spiritual, full body connection.”
Melanie, who does regular vocal exercises, feels her voice hasn’t changed due to menopause or age. “I work with my voice every day, and every day I know how
to use it better and more comfortably. Sometimes I wish I could sing lower; singing down to middle C gets a little difficult. But I don’t want to force the low part of
my voice because I don’t want to lose the high part of my voice – I still have a high C. My upper range is very precious to me.”
During midlife, Melanie had never heard of perimenopause and she experienced no symptoms. She simply stopped having periods at age 48, which is the same age
her mother had entered menopause. Melanie revealed an uncommon perspective: as a young person in the mid-1960s, she knew her own mind on nutrition and
wellness. She read food labels and had an instinct for what foods would truly nourish her body. At that time, most people didn’t know how processed foods,
pesticides, chemical cleaners, and use of plastics would poison our environment and, through estrogenic chemicals, interfere with the ways estrogen functions in our
bodies, possibly including our voices. Findings suggest that these chemicals also impact the onset of menopause. [55]
In her 30s, she became a vegetarian, way ahead of the times on adopting a lifestyle that supported her personal health. Melanie firmly believes, “The human body
needs to take its own course to heal and straighten out. Give it time to do what it knows how to do.”
Only a few months before we spoke with her, Melanie faced a terrible loss in the death of her husband. She planned his memorial, and against the well-meaning
advice of her friends and family, sang at his service. She said, “I entered into communion with my husband’s spirit and sang really well. There was a pure connection
to him, no fear, no nerves. I can hold up to anything with my singing.”
Deeply meaningful connections are one of the biggest reasons we sing. We build connections with our audiences, our communities, and other musicians. Singing
can be part of our health and wellness routines and part of our own self-care.
N O M EDICATIONS - O THER THAN C HOCOLATE
Janice is grateful for her singing journey. “What on earth else would I do? I am compelled to sing, to make music. It makes me use my brain, and move, and feel
better; it challenges me. Music is my meditation, my church, and my happy place. I love what I do! That may be the most important thing of all.” Currently age 59,
she told us that the years after menopause, which started at age 52, have been nothing short of wonderful. “My body and voice are no longer subject to the whims of
bloating, cramps, moodiness, and the inconvenience that I suffered during menstruation. I figured that I’d be in for a hysterectomy like my mother had, but all that
happened over the course of a couple years is that my periods became less frequent until they stopped. My life just went on, happily ever after. And no drugs - other
than chocolate.”
Janice went on to say, “We all go through hormonal changes our entire life. I understand many women experience more pronounced symptoms during some of
these times. I have not. No hot flashes, no trouble sleeping, no reduced libido, and no weight gain. I realize I am very lucky!”
After a 35-year long career as a classical singer and voice teacher, Janice credits her continually improving voice to great technique and excellent personal health.
Janice is an advocate for helping others find and maintain their voices and, so doing, experience improved mental health. “I have taught many women in midlife and
beyond. Most of them have had some adverse symptoms or vocal challenges. By teaching them the correct use of their voice, giving them appropriate songs for their
level of development, and having them sing on a regular basis, they find alleviation of adverse emotional and/or physical challenges and have gone on to sing better
and longer. We all know that the physical act of singing creates endorphins and the more we sing, the better we feel.” We were not surprised to hear Janice’s
thoughts about how singing can be a game changer in many women’s lives.
Menopause can have a wonderful impact on our lives. Not all physical changes from the rebalancing of hormonal levels are negative. Additionally, many of the
emotional and social changes are energizing for women, and Janice is a great example of that.
L OOKING FOR C OMMONALITIES
These five women from quite different backgrounds had very different training in various genres. They have all found that singing into and beyond menopause has
been good for them and for their voices. One sings Indian classical music. Two others sing jazz and R&B. These three sing throughout their ranges and make a point
been good for them and for their voices. One sings Indian classical music. Two others sing jazz and R&B. These three sing throughout their ranges and make a point

of keeping their whole voices in good shape. On the other hand, two women sing only classical music, and one of these eschews use of her low voice. There are two
main approaches to classical technique for women. One is avoiding the use of the low range (chest voice) which some believe leads to preservation of the high range.
The other approach is exercising the entire range, including the low range, to lead to vocal stability and balance.
Two mentioned that their older mothers still sing well - a possible genetic connection. None of these women complained of obvious voice symptoms during
perimenopause. Most told us they are dedicated to taking care of their general health as well as integrating ideas of personal spirituality into their experience with
singing.
Two of the five talked of voice health problems earlier in their careers and how working through them made them better singers in the long run. Four of the five
are still actively maintaining their voices. The two contemporary singers perform publicly and frequently, and all of these women teach singing. The two classical
singers still perform but not as much as they did before. Most interesting is that each of these vocally fortunate women pursues life with a deliberately positive
mindset. We don’t know whether this was a learned response or whether it is an innate part of their psychological fabric. Regardless, they all seem confident in their
situations, but at the same time expressed gratitude for how their voices are making the journey through midlife and the menopausal transition.
Singing is my life. It has always been my life.
It will always be my life.
Celia Cruz, Cuban Singer
Chapter 5

ROUGH WATERS
I'm not afraid of storms, for I'm learning how to sail my ship.
Louisa May Alcott, American Novelist
Much of each woman’s midlife, menopause, and beyond can feel like a guessing game, especially regarding singing, since our vocal folds are very sensitive to change.
For those of us who rely on singing as our creative and perhaps professional outlet, this guessing game can feel more like Russian roulette.
Shirley Verrett, an internationally-known opera singer who sang both soprano and mezzo-soprano roles, said in her autobiography, “By the end of the 1970s, it
became increasingly difficult for me to sing and perform. I had no idea I was in the beginning stages of menopause, which didn’t hit me until I was in my fifties…The
same thing happened to Christa Ludwig about ten years earlier. It was rough. Sometimes I could do whatever I wanted with my voice. Other times…my pitch was off
and I wasn’t fully aware of it. I was still trying to be a supermom, a superwife, a superstar...I became irritated with my husband all the time. If he said black, I said
white. Then the hot flashes and the weight gain started, my blood pressure rose, and I couldn’t sleep at night. I started off with estrogen HRT but eventually had to
change to more natural treatments. Yet I was left with not sleeping at night and a weight problem.” [56]
Women in Western cultures have only been living consistently into older age for the last 100 years. The information on hormones and the voice, while studied for
about a generation now, generally hasn't appeared in resources outside of academic dissertations, medical and voice pedagogy resources, with rare exception. It is
only in the 21st century that there has been an explosion of information on vocal health care and women's health and wellness. This new information has enabled us
to proactively care for our voices with knowledge that hasn’t been available before. There is also a transformation going on in ways to treat illnesses, as well as
ways to move gracefully into aging. This gives us the opportunity to proactively take care of our voices and our health in ways that previous generations didn’t have.
The singers in this chapter have had complex midlife and beyond experiences. They have not had textbook scenarios of gradual progression through their
transitions. Sometimes the source of their voice challenges has been complicated by underlying health issues or life stresses.
A P ERFECT S TORM FOR A S INGER
Tina is a 57-year-old career jazz and soul singer, songwriter, educator, dancer, and producer with a degree in vocal performance. Her albums have been on regular
rotation on soul radio stations for decades. Tina chuckled as she said, “One couple told me that their first born was because of me!” Over time, her career balance
has shifted mainly to teaching singing. She loves helping others sing well.
“My earliest awareness of menopause came from a neighbor when I was growing up. She was a kind nurse who helped care for my grandmother. But she had a
major personality change that turned her into a raving lunatic. My mother said, ‘She’s going through the change.’ Scared me to death.”
Before Tina’s very early menopause, she married, had two children, and was singing well. In her mid-30s her periods became irregular and varied from light to
heavy. Tina had to figure out on her own that she was experiencing a very early menopause at age 37. She remembers reading a pamphlet on menopause in her
doctor’s office. “It had a picture of a woman holding her head in agony and said that women had 30 more years of life after menopause, so I thought that meant I’d
die at 67! I was devastated.”
“I knew I was in menopause because I was crying profusely all the time - even when watching cat food commercials! I did my own research very thoroughly.
This was in the days before the ease of researching online. I read medical library research by making appointments in various medical libraries and then driving or
riding a bus there to read. I requested an FSH blood test (follicle stimulating hormone) from my doctor which she refused. But I insisted and it came back normal. I
did more research, because of how I was feeling, and insisted on another blood draw after two weeks. And there was the evidence – yes, I was in menopause. It was
a lot to take in.”
In some cases, measurements of follicle stimulating hormone (FSH) may be done to confirm menopause. If the FSH blood levels are elevated to over 30 mlU/mL
or above on several occasions, it is likely that the woman is in menopause. [57] However, it takes more than one test to confirm, because the FSH levels can vary
quite a bit as we approach menopause.
Her doctor wanted to put her on hormone replacement, but this idea didn’t sit well with Tina because, at the time, the commonly prescribed hormones were
made from the urine of pregnant horses. She followed a series of useless and very expensive regimens of natural supplements and strategies that were not based on
scientific studies. Two of these experiences were with medical doctors who declared they had discovered the answers to menopause and other health issues. Finally,
Tina ended up with a physician who practiced evidence-based integrative medicine. This doctor determined that her thyroid was not functioning well and helped
balance her thyroid levels. The doctor also treated her allergies and asthma. Fortunately, Tina did not have specific singing issues during her early menopausal
transition.
That changed in the first years after menopause. Tina said, “My voice was feeling funky even though no one else could hear any change.” She went to a highly
recommended otolaryngologist, who diagnosed a cyst on her vocal fold. She was told it needed to be surgically removed. This procedure is not uncommon, and so Tina
went ahead with it.

Vocal Fold Cysts [58] [59]

Vocal fold cysts are “self-contained sacs of fluid or semisolid substance within the vocal fold”, according to
Leda Scearce in her book Manual of Singing Voice Rehabilitation. Singers complain of difficulty with high notes, vocal
instability, increased effort to sing, and a rough or harsh sound, similar symptoms to those of vocal nodules.

Vocal fold cysts are not necessarily caused by vocal misuse or poor technique. The cause may be unknown or it
could be related to other vocal fold issues, such as a tiny, clogged mucous duct.
Unfortunately, Tina’s vocal saga continued. “After treatment, when I began gigging again, sometimes I opened my mouth to sing and two pitches would come out
at the same time, and not on purpose! I was frantic, frustrated, and angry. I did not know what would come out as I tried to fulfill my performing contracts.” Clearly
something was terribly wrong.
Tina went to two more otolaryngologists in two different cities and was finally diagnosed with acid reflux, which had inflamed her larynx, as well as a mild
neurological weakness of one vocal fold and cysts on both her vocal folds. She had one more surgery and subsequent recovery period, and after slowly easing back
into singing, Tina was finally back to performing and recording again. Prolonged stress was also playing a role in Tina’s life. Along with the career impact from her
troubled voice, she went through a divorce and became the sole financial provider for her two children.
Now 20 years post menopause, Tina’s fierce tenacity and drive keep her singing. She told us, “Singing is my livelihood, yes; but it is like a bad boyfriend. It beats
you up. It’s abusive. But I keep going back. I came into the world as a singer. The stage is home.” Despite those feelings, she told us that “singing is the most
sensual, grounding, and visceral experience. I’ve never felt such emotional freedom! That’s something the pamphlets don’t tell you.”
Tina recorded her latest album several years ago, wearing her multiple hats as singer, song-writer, producer, and arranger. However, she felt she struggled
vocally through much of it. To work with the best parts of her voice, she arranged her vocal line with clever collaborations from her band. “I was getting ready to do
a European tour to promote my new album but decided I still have foundational work to do. I have done some voice therapy work with a skilled colleague. The vocal
rehabilitation process, while slow and expensive, does garner strength and flexibility. I am somehow growing into my voice as it is now, not holding on to some
version of a younger self.”
Tina’s story brings up a lot of questions:
How did the nerve supply for one vocal cord become so weak that vocal dysfunction occurred? This is not a "lack of technique" issue. Nerve dysfunction, such as
the paresis Tina suffered from, has multiple causes and can occur in anyone of any age, so it is difficult to determine why it happened in Tina's case. [60]
Why did her menopause, at 37, occur so much earlier than average? Tina had been diagnosed with a thyroid condition; her thyroid hormone levels may have
played a part. Thyroid disease can cause premature menopause.
Since low thyroid levels can cause hoarseness and dryness, did this add to her voice issues? What caused the vocal fold cyst to form? The medical community
and experienced voice specialists can’t be certain about what caused Tina’s vocal fold issues.
It is highly possible that Tina's issues were not the result of poor technique. We should avoid the easy and judgmental trap of assuming that all voice problems
are the result of "bad technique" or voice mis-use. They may be the result of a "perfect storm" of several subtle causes. Understanding the possible complexity of
vocal issues is key to understanding singers. A human body is not a collection of separate parts. It is an integrated system. Fortunately, newer science is examining
these interactions via the fields of psychoneuroendocrinology and psychoneuroimmunology, which seek to understand overlapping body systems via interdisciplinary
research.

T HYROID I SSUES
Early menopause can be brought on by thyroid conditions, including Hashimoto’s Syndrome and Grave’s Disease. Thyroid dysfunction is surprisingly common in women.
According to the American Thyroid Association, women are five to eight times more likely than men to have thyroid problems. [61]

Women should be aware that symptoms of thyroid issues are similar to those of perimenopause. Symptoms for the specific conditions can include:
Hypothyroidism: extreme fatigue, depression, forgetfulness, and some weight gain.

[62]
Hyperthyroidism: heart palpitations, irritability, nervousness, muscle weakness, and sleep disturbances.

In addition, it’s possible for women who are experiencing wide hormonal fluctuations over time to experience signs of both hyper- and hypothyroidism. Be
sure to describe all symptoms you may have from both lists to your health care provider.

All women should be aware of the symptoms of thyroid problems. For women experiencing symptoms, especially women who are younger than 40,
requesting a full thyroid panel is advisable. If early menopause is suspected along with thyroid problems, proper treatment of the thyroid may delay the onset of
menopause.

C AREER C HANGES THROUGH H ORMONAL T RANSITION

Helen, age 50, is an energetic and physically fit soprano who sang for many seasons with one of the world’s leading opera houses. She left the opera scene after she
married her soulmate; she was ready for a steady life. She is now happily teaching at a university.
During her 40s, Helen was experiencing many typical menopausal symptoms: hot flashes, mood swings, night sweats, nighttime anxiety, weight gain, and bloating.
She was surprised by one issue that most people don’t realize is a perimenopausal symptom: “I can’t bear to be hugged right now – even by my sweet husband. My
chest is too sore. My breasts are lumpy and sore all the time. It’s horrible. I’ve never had that kind of pain before. I was so worried. I went to the doctor. I even got
several breast infections. But, apparently it’s just a symptom of hormone change.”
Helen is dedicated to eating healthily and getting daily, intense exercise. When she unexpectedly gained weight in spite of not changing her exercise or diet, it
really threw her. She said, “I feel out of control! It doesn’t matter what I eat and how much I exercise, I can’t seem to drop that weight! It’s not a body I recognize;
it feels so foreign to me.”
An additional issue makes Helen’s menopausal transition more challenging. When she was in her early 40s, she developed benign fibroid tumors in her uterus,
which led to heavy vaginal bleeding. It was severe enough that she had a hysterectomy, so she hasn’t had periods since then. She still has her ovaries. Typically,
when we move into our perimenopause years, if we have a uterus, gradual changes in our periods can help us determine that we are heading towards eventual
cessation of menstruation. Women who don’t have their uterus are unable to track changes in menstruation. And though Helen wanted to consider hormone therapy to
smooth out her troubling physical symptoms, her family has a history with cancer so she is not a candidate for HT.
“Throughout my 40s I started wondering, as my body was changing, what might happen vocally. I learned that voice changes could be a thing and started to read
more about it. As time went on, I noticed that I was less comfortable in my top range, and my voice felt less flexible. My vocal folds felt swollen. When I hear my
singing, I still enjoy the sound, but it’s heavier. On the other hand, my bottom range is full and warm. And I find that my voice is happier right now in popular music
like ballads and jazz standards.”
Helen told us that during a visit with a laryngologist, they found a tiny area of swelling on one vocal fold that seems to come and go, mainly associated with
illness. She has learned to manage it with patience, careful vocalizing, and wise voice use. Helen was relieved to be able to talk to us without fear of being judged. “I
have to back off of performing now and feel grief and frustration that I am losing something so important to me. People talk about me as an opera singer and I say,
‘I was, but I am not now.’ However, I am sincerely accepting of my new identification as a voice teacher with developing voice science research interests.”
Helen will soon be reviewed for tenure at her university. Tenure is essentially job security until retirement and requires a rigorous evaluation by administration
and faculty colleagues. “I am somewhat concerned that my voice changes may affect my tenure process. Fortunately, conducting research and publishing my
discoveries can be substituted for performing.”
As for how Helen is holding up, she shared, “I have incredible sadness, but it’s not depression. I feel like I’m losing something important – like the loss of a pet
or close relative. I’m losing myself a bit. It makes me think strange things; how do I get my younger self back?” She chuckled, “I understand now why some women
get treatments to look younger – you know, Botox, that kind of thing! All the same, I still have a healthy perspective. I really am working on how to let go and
transfer to a new stage.”
Based on the experiences of others, we believe that though Helen has been in the midst of a perimenopausal storm, symptoms will likely calm down in the
future. As the hormones rebalance in postmenopause, with some recalibration of technique and continuation of her already healthy lifestyle, it’s quite likely that she
will be able to resume performing with confidence. Perhaps she may end up with a slightly different tone and range, but there will be no loss of her vibrant
personality and verve.
Helen isn’t alone in adjusting her career during midlife. For some women, circumstances force them to change. For others, circumstances finally allow them to
transition. Redefining ourselves is a common occurrence in midlife. Countless women say that they enter into unprecedented periods of creativity, energy, sensuality,
and freedom. They wouldn’t go back to their younger selves for anything. However, many of us feel that we ourselves are doing something poorly, or that there is
something wrong with us, when symptoms catch us unaware.
Helen retired from singing opera not because she was having voice problems; these came along when she was in perimenopause. But her descriptions of her
voice changes and the challenges they offered when she tried to sing her familiar opera repertoire are similar to what classical singers sometimes report. They help
us understand why some women decide to step back from performing their accustomed repertoire and operatic roles in perimenopause or after menopause. For
sopranos especially, physical changes to the small structures of the larynx may make it feel heavy, sluggish, and inflexible. It becomes difficult to sustain long, high
phrases, a hallmark of this repertoire. No matter how singers try to work around it, if the voice continues to feel unpredictable and uncomfortable enough, some
phrases, a hallmark of this repertoire. No matter how singers try to work around it, if the voice continues to feel unpredictable and uncomfortable enough, some

singers make the heartbreaking decision to step away from their careers. They can’t simply decide to become a professional mezzo soprano because in many cases
their sound or the range demanded to sing these parts isn’t a good match with the natural voice. Consequently, some migrate their careers to teaching or other
related fields. They may change keys of their songs, or move into different repertoire and types of music. When these options are used by singers of other genres, in
many cases it isn’t considered a problem. For an opera singer, the expectations of the voice in a particular role can’t be changed. There are traditional ideas of what
the voice should sound like in a given role. The keys of the arias can’t be lowered. As a result, the singer has to go where the voice is leading.
S ELF- B LAME A DDS TO THE S TRUGGLE
Maggie is a dynamo – irrepressible! So much so, that you’d never guess that she has been through some really tough times, emotionally, physically and vocally. Now
58, she is a much sought-after contemporary singing teacher and performs in her genres of choice: American and Brazilian jazz, blues, and pop. Her journey as a
singer started at church. She was a natural singer and wanted to keep it that way. “I didn’t want to sound trained,” Maggie said emphatically. “To me, trained singers
didn’t sound connected to their heart, they sounded afraid, restricted.”
Nonetheless, in her 20s she ended up taking a group singing class with a teacher who said she could help her. It did not go well. Maggie recalled, “It was a real
disaster in the worst sense. I developed severe laryngeal spasms and nodules (tiny bumps on the vocal folds which oftentimes result from voice overuse). We worked
on the exercises in classes - men and women together. So, the teacher never heard me and what happened to my singing.”
Maggie also struggled with thyroid issues, but in a particularly heartbreaking way. “I developed Hashimoto’s after my father died suddenly. Because of the nature
of how he died, I always felt it was my fault, even though it wasn’t. I always wondered if my thyroid went crazy because of grief and stress, and the fact that it
took years to straighten out my singing issues.”
Hashimoto’s disease is an autoimmune disorder that affects the thyroid gland. It is much more common in women than in men. Some of the symptoms of
Hashimoto’s disease, including hoarseness and vocal fold dryness, are similar to those of perimenopause. Hashimoto’s is also associated with premature menopause.
[63]

Maggie told us, “I found a good medical doctor who recommended a skilled voice teacher for me. The doctor put me on prednisone (a steroid to reduce swelling)
to help treat the nodules and synthroid (thyroid hormone) that helped stabilize thyroid numbers. And then I stopped menstruating about age 40, but I just thought
something was wrong with me. I was sort of oblivious. I was used to feeling horrible; so if there were perimenopausal symptoms other than Hashimoto’s, I wasn’t
aware of what they were.”
Through all the physical and emotional upheaval, Maggie kept working to improve her singing. She found a teacher who specializes in rehabilitating voices. “Even
though I had been improving vocally, I began with this teacher three times a week for two years. I went to her because my singing still felt like it had no flexibility,
was tight, and it certainly didn’t feel easy.”
Fortunately, her singing continued to get better over the years. Along with some important technical adjustments, Maggie said she “had to make many ego
readjustments. And, as I have gotten older, I’ve learned to let go of many ego attachments, such as ‘I must do it right .’ I have let go of the need to be the authority
and am also kinder to myself.” Maggie has learned, along with so many of the women we interviewed, that releasing unhealthy perfectionism is one of the keys to
entering the next stage of life – vocally and otherwise.
T HE E MOTIONAL C ONNECTION
Angela, age 47, is a career jazz and R&B singer, songwriter, pianist, and vocal jazz educator who’s taught in public school and college. She’s also a single parent of
two children. As for her stage of perimenopause, her infrequent menstrual periods lead her to believe she will be postmenopausal soon.
“I can’t really pinpoint the beginning of my vocal and health issues, but they seemed to coincide with my very difficult divorce and the start of coming into my
own as a woman. I experienced insomnia, urinary incontinence, lack of libido, hot and cold flashes, acne, and hair thinning. In the early stages I looked at all these
symptoms as problems with me. I wasn’t doing enough Kegels, or I wasn’t strict enough with my diet, or I didn’t believe in God enough, or any number of other
things.” Angela may have developed some of these thoughts from knowing about her mother’s menopause. “She told me her menopause occurred at age 47 - after one
hot flash. She decided it was foolishness and that she would not succumb.” Her mother was the kind of person who was determined to control her menopause with
stoicism. “I don’t know if she really did,” Angela offered, “but it sure seemed that way.”
Angela developed major acid reflux that she felt was connected to anxiety and began experiencing severe spasms of her esophagus and larynx. These spasms led
to unrelenting coughing fits and increased incontinence (bladder leakage).

L ARYNGOPHARYNGEAL R EFLUX ( LPR ) AND G ASTROESOPHAGEAL R EFLUX D ISEASE ( GERD ) [64] , [65]
Acid reflux is a common condition and incidence may increase in women during perimenopause and postmenopause. A large study found that perimenopausal and
postmenopausal women were nearly three times more likely to have reflux than premenopausal women. [66] In general, singers may experience reflux more frequently
due to the added pressure on the muscular valve at thetop of the stomach when they sing, and they are particularly sensitive to its effects on the voice. Lifestyle,
diet, and stress also play roles.
With reflux, the acid that comes up to the level of the vocal folds and throat plays havoc with the voice, causing swelling and irritation of the tissues. Not all
people with reflux experience burning or discomfort in the chest (heartburn or indigestion). Silent reflux, or LPR, may cause seemingly unrelated symptoms like
coughing, nasal and sinus drainage, lump in the throat, thick mucus, or even asthma. Voice users may be sensitive to hoarseness or low voice in the morning, vocal
instability, and prolonged warm-up time.
If these symptoms occur regularly, a voice doctor should be consulted. With a diagnosis of reflux, there are a variety of treatment options to consider, from
lifestyle and dietary changes, to forms of body work, to medications. Once the irritation of the larynx is resolved, the voice should improve, though it can take a
number of weeks to heal. If singing continues to be difficult, voice therapy or specialized singing instruction may be needed.

Angela’s coughing became so intense it would regularly cause her to vomit. “Sometimes I wet myself so badly with the harsh coughing that I couldn’t gig or
teach and had to back out of the room or off the stage. And I am a single parent raising two daughters without their dad in the picture.” Self-employed musicians,
many contracted adjunct professors, or independent teachers have an additional financial burden when health problems arise. When they cancel, they don’t get paid.
She went on to say, “I didn’t seek medical help because I had been taught to suck it up, never admit weakness, and move on. This is what being a strong woman
meant to me then.”
But eventually Angela did start to reach out to colleagues, read on her own behalf, and changed her cooking and eating style. “I sought medical advice for the acid
reflux but didn’t want to go on powerful acid suppressors. I did not know that crying was healthy until my mid-40s, or that the pain in my throat could not be healed
until I dealt with my life and emotions. Through all of this I have learned a great deal about my body’s personal psychosomatic responses to stress, including grief,
anxiety, and worry.” Angela shared that, “I needed emotional healing and had to learn to recognize my own habits and thoughts. I had to recognize the immense
amount of anger and fear I’ve had living in the United States as a woman of color. If you are always feeling like the victim, you can’t overcome anything.”
As Angela talked about the integral link between her emotions and her vocal health, she made it clear that things are getting better. “I have gotten older and
changed from the inside out. The voice has gotten more reliable and more fluid.” Over time, Angela got further from her divorce and stronger within herself.
Simultaneously the acid reflux and coughing became better. “Several things I did to help this transition was that I started a spiritual curriculum to help me focus on
my blessings and learn to trust that help is around me. It was a huge step in becoming vulnerable. I also take occasional voice lessons with two voice teachers who
work with vocal rehabilitation, somatic awareness and performance strategies. I have learned that I can work with my body instead of against it.”
The tie between emotions and voice is key to expressing and understanding ourselves. In fact, as singers we rely on it for storytelling. But sometimes we don’t
realize the authentic struggles in our lives can have a long lasting and dramatic impact on our vocal health and expressiveness. Additionally, chronic stress can bring
about health issues such as acid reflux which also impact our voices.
This complicated web of cause and effect can take time to sort out. Kathy Mattea, American country and bluegrass singer, said in an interview with Rolling
Stone magazine, “It was good to have the voice practice to anchor everything. It was like, ‘OK, I can’t do anything about Dana’s cancer, but I can practice my voice. I
can do something to answer this question.’ The hardest part is just hanging with it unresolved until you get clear.” [67]
I NTERCONNECTED I NFLUENCES ON S INGING
The women we’ve heard from in this chapter show us that very often our menopausal paths are not linear and that singing, hormones, and health are interconnected
at the deepest levels. All of our body’s systems are meant to be in communication, and that includes our brains and emotions. On top of that, many women blame
themselves for symptoms. They talk about feeling like something was wrong with them, instead of understanding that they were experiencing a natural process.
Oftentimes the medical world looks at body organs and systems as separate and self-contained processes. Fortunately, integrative therapies and medical science
are working together to provide more evidence-based healing tools based on the interconnectedness of all of our systems. Recent science is examining the
relationships among physical and emotional systems.
Nonetheless, each woman going through midlife and into older age is on her own journey. In the same way, our hormones fluctuate, rebalance, and adjust their
relationships to each other; and we might find we need to rebalance our relationships: relationships with others, ourselves, our living and working environments, our
communities, culture, and religious beliefs.
Dr. Sara Gottfried, a gynecologist well known for her work on hormones, lifestyle, diet, and aging, suffered from a serious vocal issue. In a statement from one
of her programs, Dr. Gottfried said about her voice, “I’m not in charge or in control. There’s a spiritual quality to the weakening of my voice, an uncertainty about my
future that can be either a downward spiral or an upward spiral, and I’m actively choosing the upward spiral. I’ve had to completely surrender, which is very hard for
me because I have a strong will. Usually I can push harder, work harder, strive, and achieve my way through anything; but that approach has limits when it comes to
my voice. So, I’m learning how to surrender to what’s true right now, in the present moment.” [68]
This is not the end of the story for any of these courageous women. They are all striving to understand how their emotional, physical, and vocal selves are
woven together. We find it fascinating that they are all singing teachers. They are living out the wise woman role, mentoring others in our craft. The women of this
chapter have stayed the course. Ultimately, they find their bearings by accepting themselves and their circumstances, while mastering the power to persevere, adapt,
and change.
Yesterday I was clever, so I wanted to change the world.
Today I am wise, so I am changing myself.
Rumi, Persian Poet and Sufi Master
Chapter 6

SINGING THROUGH THE HARD TIMES

Courage doesn’t always roar. Sometimes courage is
the quiet voice at the end of the day saying
‘I will try again tomorrow.'
Mary Anne Radmacher, American Author
One of the undeniable facts of life is that we are all vulnerable to illness. Many people believe that the older we get, the higher the odds of serious health issues.
Philosophers and theologians struggle to understand the “why” behind life’s difficulties. Medical practitioners seek solutions. Thankfully, countless composers and poets
give us music and texts we can use for coping.
Singing, oftentimes in a group, can be a treatment for better health for many who face the unexpected demands of illness. Singing can also provide a goal that
motivates us to pursue better health. In our quest to shine a light on the challenges of singing through midlife and aging, here are the stories of some remarkable
women who have met and dealt with special health challenges.
M USIC M AKES M E F EEL B ETTER
Patricia, age 53, is a life-long singer and professional pianist. She loves working as an accompanist and directing community musical theater. She also enjoys singing
in musicals and groups.
After she had her children, she noticed that her voice had lost some high range and was darker in color. She went back to voice lessons in her 40s because, after
a ten-year break, her throat felt tight; and she realized she needed help with her vocal changes. Her voice teacher helped her reconfigure and move from soprano to
mezzo repertoire. “In general, I really like my voice now.”
Many of us were assigned a voice type - soprano, mezzo, or alto - when we were in our teen years, and we continue to claim that voice type as part of our
identity as the years go by. But our voices are not stagnant; they change over time. Because of that, some who sang a certain choral part in high school, or were
trained in college for a voice type, don’t realize that the voice evolves as we mature. This process doesn’t have to do so much with hormone changes of midlife and
beyond as with the physical evolution of a singer’s natural instrument. As we mature and develop from our teen years on through the rest of life, our voices naturally
change. On top of that, skilled musicians will often be asked to consistently sing different parts in choirs and ensembles whether or not it fits their natural voices. It
may be helpful for the group, but not for the individual.
Patricia’s journey involved more than slight changes to her voice. Around the time she went back to her voice teacher, she started experiencing perimenopausal
symptoms, such as hot flashes, insomnia, and memory issues. Then she developed a chronic autoimmune disorder called ulcerative colitis. It is a painful disease that
inflames the digestive tract, and due to frequent bouts of diarrhea, can impose frustrating lifestyle restrictions. It requires a special diet and medications to manage
the symptoms.
Patricia admits that dealing with a chronic health problem isn’t easy. “So much of my time and energy goes into managing my symptoms, from diet to lifestyle
changes, to integrative health approaches, to medications. But I can’t control when episodes flare up. Sometimes I am too wiped out to sing. It’s ironic because I
know singing makes me feel better, but I literally cannot summon the energy to sing when I am also teaching and coping with chronic pain.” Management strategies
and/or medications can improve quality of life. Gathering together to support each other can make a substantial difference as well. Patricia continues to bring her
friends together regularly to commiserate about menopause and life.
Nearly 80% of people with autoimmune diseases are women. [69] Researchers are pursuing a number of theories to explain possible correlations between the
female body and immune disorders. No matter the cause, autoimmune diseases are exhausting and painful, and can limit activities, stamina, and joy. They can even
cause those who have these conditions to sense that something is wrong with them at a core level and to doubt their self-worth. To add to their distress, people with
these conditions may encounter medical caregivers who don’t believe their complaints. [70]
S INGING AS A H EALING M ETHOD
Singing has been used as a form of healing since ancient times. However, we are now in the middle of an explosion of scientific information confirming the healing
properties of singing and music. Singing can be one of the easiest, least expensive, and most immediately available therapies we can each use.
There are many studies showing the correlation of singing to health. These studies have shown improved mental health, memory, and outcomes from surgeries
by those who participate in music. [71] Music has been shown to have positive impacts on conditions such as brain injury, asthma, pain, and neuromuscular disorders.
[72]

The understanding of the relationship between music, singing, and health is drawing increased attention through research funding from organizations like the
University of Oxford, the U.S. based U.S. National Institute of Health and the National Council on Aging, SEMPRE (the Society for Education, Music and Psychology
Research), American Psychological Association and countless other institutions around the world.
S INGING C AN B E THE R EASON FOR R ECOVERY
Emma is 60 and about 10 years postmenopause. Until her late 40s, she was a professional athlete. In addition, she is a licensed bodyworker with a busy, successful
practice.
When she was 47, Emma decided to give up her athletics and dedicated that time to serious singing. “I knew that I couldn’t do both, so even though it was a
hard decision, I decided that if I was ever going to really sing, this was the time.” She takes voice lessons and sings in choral groups, often as a soloist. Her favorite
genres are classical, musical theater, and the American Songbook.
“I only had one hot flash at about age 45,” Emma reported. “It was like ‘Wow!’ and I was suddenly in a sweat from head to toe. I had other symptoms like
depression, sleeping problems, and a mild low-grade migraine for two weeks at a time. I went on progesterone for hormone therapy, but after a traumatic head injury
I went on a combination of progesterone and estrogen to avoid memory loss. Thankfully, I have received the other health benefits of being on hormone therapy.”
Sadly, Emma had to face yet another serious health challenge years later. When she was 58, she developed a life-threatening case of sepsis. Recovering has been
the health issue that has most affected her singing. “I was near death,” she revealed, “and spent several months in a nursing home, requiring extensive physical
therapy.” Our bodies know how to release chemicals into the bloodstream to fight an infection, but sepsis occurs when the body’s response goes wildly out of
balance, triggering changes that can damage multiple organ systems, connective tissue, muscle, and bone. Though previously “buffer than shit,” she had to rebuild her
body, which was severely weakened by her illness. “In fact,” she said, “I needed knee surgery later after I healed.” Needless to say, Emma did not sing for at least 6
months because she was so sick. Prior to all of this, she had been singing for several hours a day.
The opportunity to go on a choir tour to Europe helped motivate her to get her singing back in shape. “It was hard to start up again, and took several weeks; but
I ramped up my practice time and was able to go on the tour. I don’t feel like I am entirely back to ‘vocal athlete’ status; yet I keep working at it. I sing every day.
I have to breathe a little more often. I’m still working on building my aerobic capacity and stamina, but that’s ok for now.”
S INGING B EFORE, D URING, AND A FTER C ANCER
Carolyn, now 51, is an upbeat soprano who enjoyed a career in opera and musical theater in the United States and Europe, completed advanced degrees, and began
teaching voice at the college level. In the midst of all this activity, Carolyn married and had four children. Life seemed to be going according to plan, but when she
was in her late 40s, Carolyn developed unusual and profound fatigue. At first, she and her doctors chalked it up to “age” and typical stresses. But it wasn’t long before
new, obvious, and frightening symptoms led to a diagnosis of a blood cancer. Her symptoms included growth of the lymph nodes in her chest to golf-ball size. Her
breathing was impaired due to their size. Her diagnosis was Stage 4 Hodgkin's lymphoma, with occurrence above the diaphragm only.
After diagnosis, Carolyn performed with a symphony orchestra and then, only a week later began chemotherapy treatments. She managed to continue teaching,
even with chemo treatments every two weeks. “I kept my voice going by singing and demonstrating, but I didn’t do any actual performing. After about two months of
chemotherapy my periods stopped, and I started having hot flashes and night sweats.” Carolyn, as expected, had entered medically induced menopause due to the
drugs used in her chemotherapy. She was told that her periods might start up again, but it was unlikely they would due to her age. Her treatments ended after six
months. During that time she didn’t notice any voice changes. All the same, the first time she sang, off the cuff in front of friends, she wasn’t sure what would come
out of her mouth. “But it felt so easy! There are a lot of unknowns. I was really amazed at how little impact menopause and the chemo had on my voice. You’d think
that all that medication going through my body would have an effect on my voice, but it didn’t.” It also helped that treatment had reduced the enlarged lymph nodes
to normal size, so they no longer interfered with her breathing.
To Carolyn’s and her medical caregivers’ surprise, her periods started up again a few months after the end of her treatment, so now she is in perimenopause. “I
really can’t complain about my voice. Singing is a joy to me! But I have to warm up these days! I used to be able to roll out of bed, say a few things, and I was
ready to sing. Now, maybe due to age or changing hormones, I have to work a lot harder to remain a vocal athlete.”
When we asked Carolyn how she managed the stress of cancer, she replied, "What helped me the most was mental wellness. My husband would say, ‘Don’t go to
the dark side – stay on the bright side of things.’ My inner dialogue was: ‘What am I learning from this? I can’t dwell on the negative results. Cancer isn’t going to
define me. Don’t let life happen to you. Approach every day with freshness and positivity. That frame of mind was really helpful for me.”
For any singer who goes through various kinds of treatments for cancer, the potential effects of drugs and medically induced menopause on her voice will
probably not be at the top of her priority list. Finding time and energy to keep the voice going during this critical set of events might not be possible. Also, each
woman’s reactions to the variables of the illness and treatments would be hard to predict. Allowing the feelings of sadness and anger is important, but at the same
time, learning or choosing not to dwell there is crucial to healing.
S INGING WITH V OCAL F OLD P ARESIS
Kara, 45, has been in perimenopause for about a year. Kara had an unusual singing career. She used to perform in musical theater, and because of her petite size, was
cast in children’s roles until she was 35. Eventually she got tired of playing adolescents. “I couldn’t figure out how to transition into adult roles, and it was hard to
break out of what I had become known for. So that’s when I began teaching singing to children.”
She believes she is in perimenopause because of changes to her menstruation, long stretches of breast tenderness, and random pangs of cramping for about half
the month. She also reports being irritable. When we asked her if she has access to good health care, she reported, “I’ve always gone to Planned Parenthood for my
gynecological health, as I did not have health insurance until recently. I plan to find a gynecologist soon.” As for her voice, “I noticed that my whistle register doesn’t
function - my voice just doesn’t go there anymore.” Whistle register is a name for the highest vocal register.
There is a possible complication to her vocal picture. “A year ago I caught a virus and afterwards had a large ‘break’ in my middle voice. I could no longer sing
evenly in my middle range.” Her teacher suspected she might have vocal fold paresis because the problem followed an upper respiratory infection. This is a common
scenario for the onset of paresis. Unfortunately, due to her lack of medical insurance, Kara couldn’t afford to see a laryngologist so didn’t get a diagnosis.
As an experienced musical theater singer, Kara had been adept at singing efficiently in her middle to low ranges. But, after her cold was over, she suddenly lost
that critical coordination. She described to us, “I frequently cracked. It was extreme. My voice would essentially just cut out in the middle; and then the sound that
came after would be very weak until I got past that range in my voice. It was kind of like hearing a young male who is learning to smooth out the registers going
from chest to falsetto where it cuts out and then flips into head. It was like a hole had developed in my voice.” Over the past year she has worked hard with her
teacher to figure out a way to handle the problem. “There always seems to be something in my throat in that area. I have learned to sing around it. I have to either
go headier or lighter than in the past, depending on which way the melody is going - up or down. Others say they can’t hear it. But it certainly is a lot more work - in
my head and in my throat - and it’s not very joyful to sing that way.” All the same, she says she can sing what she wants to sing. It just doesn’t feel as much like a
natural process as before. (Please see appendix on Vocal Fold Paresis.)
Kara told us that while working with her voice teacher, she began researching explorations into “polyvagal theory” as a possible source of healing. [73] Polyvagal
theory is the idea that the condition of the central nervous system affects the function of many other systems in the body, including the voice, and may impact other
physical conditions and diseases. This insight has led her to continue to investigate the implications of low vagal tone for the nerve supply to her vocal folds.
C OMPLICATED V OCAL C HALLENGES
Hope, 66, is a committed amateur singer. She has sung in a Sweet Adelines barbershop chorus, church choirs, and community musical theater productions. She has
also taken voice lessons since she was 39 and currently conducts a church choir. On top of all that, she started teaching elementary school music in her mid-50s.
Hope feels she could have entered postmenopause more gracefully if she’d had better medical advice. “I stopped taking birth control pills at age 56. My doctor
didn’t tell me to go off the pill gradually. If I had stopped more slowly the hormonal change wouldn’t have been so abrupt. The hot flashes were terrible!” she
remembered. “I did find an over-the-counter supplement that helped a lot. I also read that some women are helped by HT to keep their voices more flexible, so I
requested some. The HT has helped vocally a bit.”
This was around the same time she had started teaching elementary school music. In addition to the abrupt shift in hormone levels, Hope came down with
laryngitis on the first day of class. “I could not make a sound for 3-4 days. My doctor gave me antibiotics and steroids. The voice came back very slowly, but I had
no singing voice and a very gravelly speaking voice.” She spent years consulting with ENTs and speech-language pathologists before she received a correct diagnosis
of unilateral vocal fold paresis. Some of the contradictory information she was given included: “Your voice is fine,” “You have muscular problems from forcing your
voice,” “You have nodules and need voice rest.”
Her voice kept getting worse. “I couldn’t get enough breath to sing or speak, and I had a very limited range,” she said. “My speaking voice was reduced to a vocal
fry. I just kept forcing myself to speak and sing and could not sing on pitch.” Clearly Hope had not received the voice care that she needed. It is important to
continue seeking out knowledgeable medical care for those who find the professional advice they’ve received is not helping.
For anyone who uses the voice when it’s compromised and continues to “push through,” the body will try to help with compensatory behaviors, which result in
throat tension. These temporary strategies can become dysfunctional long-term habits. For school teachers and other professional voice users, it is difficult to take
off enough time from work for a dysfunctional voice to recover fully. Over time, it is possible that Hope got into some poor muscular habits that made talking and
singing even harder.
With the passing of time and developing awareness, Hope is still singing and taking voice lessons. These days, her voice reacts with more sensitivity to things in
her environment and lifestyle, such as allergies, adequate sleep, and hydration. “I do feel that my voice is more fragile now. But I know what to watch for. I just need
to remember to do the things I need to do to keep it in good shape. And looking back, I have to say that being a school teacher did take a toll on my voice. I started
to use a microphone which helped.”
Unfortunately, Hope still carries feelings of grief. “The barbershop chorus I was in participates in competitions, and I had to pretend to sing much of the time. I
thought my singing days were over which depressed me. However, my voice is coming back slowly. I pursue singing because it brings me joy, allows me to feel
beauty, and express myself. I have found out that the voice is hugely affected by menopause and my current otolaryngologist seems very knowledgeable. I have
continued to educate myself through summer vocal pedagogy workshops and education opportunities about the aging voice through Sweet Adelines and with the
American Choral Directors Association.”
The issues the women in this chapter faced were challenging ones because the matrixes of physical and vocal ill health were complicated. When hormonal shifts
were folded into these scenarios, it may have made the situation even more confusing. These women are inspiring in their resilience and their determination to
recover. Additionally, they all understand the incredible healing power of singing, both mentally and physically. We are truly grateful for their willingness to share their
stories with all of us. When we have gone through confusing, complex struggles, it is tempting to choose to not talk about it; but by sharing our stories and our
struggles, we all grow together. Each story provides an opportunity for other women to find their own way through challenges.
Nothing heals us like letting people know our scariest parts: When people listen to you cry and lament, and look at you with love, it's like they are holding the baby of
you.
Anne Lamott, American Writer
Chapter 7

EXPLORING ALTERNATIVE METHODS

I used homeopathy, acupuncture, yoga and meditation in conjunction with my chemotherapy to help me get stronger again after the cancer. I also chanted with
Buddhist friends and prayed with Christian friends. I covered all my bases.
Olivia Newton-John,English-Australian
Singer, Songwriter, Actress, Dancer, and Activist
When co-author Nancy Bos’s first child was born prematurely, it was fortunate he was born at a modern hospital with all of the life-saving devices a preemie may
need. The baby’s life was saved by technology.
But once Nancy’s newborn was released from the hospital his skin began to yellow. It was a case of neonatal jaundice. With jaundice, if bilirubin levels stay too
high there is a risk of harm from it accumulating in the brain.
The treatment was a surprise. “Really, we put him in a sunny window without any clothes on?” was Nancy’s response when the doctor told them what to do.
“Yes, indeed!” the doctor replied. “This treatment breaks down bilirubin into harmless byproducts.” [74] Within days of beginning treatment, the jaundice was gone.
Light therapy, which has been used for healing for centuries, couldn’t be explained by science until the 20 th century. Now, in the 21 st century, there are many ways
light therapy is being used. Some of these include treating skin conditions, cutaneous lymphoma, and depression. [75]
What does light therapy have to do with singing and our voice changes? Even though scientists and doctors didn’t understand how or why light therapy worked, it
was helpful and they used it. In a similar way, a number of the women we interviewed found help as they moved through menopause and aging challenges by using
alternative methods of healing, though in some cases the methods are unproven by scientific methods. To those of us who are rooted in traditional, evidence-based
Western medicine, some methods may seem like a stretch - maybe even unbelievable. Nonetheless, just as science eventually discovered that the blue spectrum part
of sunlight cures jaundiced babies, perhaps unverified alternative methods will be proven effective by future scientific research. Some of these methods include energy
therapies that access the body’s electromagnetic field.
The biofield, the energy field of living systems, offers a new perspective complementary to the mainstream biochemical view of life. It is Mother Nature’s original
Wi-Fi - the basis of a new communication system in biology - in which invisible fields transmit key bio-information. It is the basis of energy medicine whereby the
softer, gentler therapies act in harmony with the body’s innate dynamics.
Dr. Beverly Rubik, Biophysicist [76]
Modern medicine has been familiar with the healing and diagnostic properties of our body’s energy systems for quite a while. It uses them diagnostically, such as
EKG (electrocardiogram) which measures the electrical activity of the heart, or a basic thermometer which measures the body’s thermal energy. Medicine uses other
forms of energy, such as ultrasound for sonograms and red light therapy (low level laser) for wound healing. Additionally, there are contemplative practices that
utilize the body’s own systems to heal and restore, such as prayer, religious rituals, visualization, imagination, and meditation. Scientific and experiential evidence
shows that perceptions in our minds are reflected in the chemistry of our bodies. [77] Contemplative practices literally change the expression of our cells.
These are just a few examples of alternative healing methods. As we cover some of the other methods the women shared with us, we’ve kept in mind a simple
understanding of proven and unproven energy.
Proven energy: measurable and scientifically proven to exist, such as the use of light therapy for neonatal
jaundice.
Unproven energy: not measurable with current technology and therefore, not considered part of current science,
such as Reiki. [78]
The late Dr. Meribeth Dayme, an influential, visionary scientist, teacher, and author, emphasized looking at a broad picture of energy to understand how it works
in singing. In her book, Dynamics of the Singing Voice, she quoted a concept outlined by J. Diamond:
“…‘life energy’ [is] a vital force that is physical, mental and spiritual in nature: the physical being reflected in the muscular activity and the functioning of the skeletal
system; the mental, including thoughts and the ability to be centered; and the spiritual that begins as spirit which is signified by the love and humanity within each
person. ...everything in the environment, both physical and psychic - thoughts, feelings, desires affects life energy.” [79]
It is through that combined physical, mental, and spiritual lens, that we look at the stories from these women who gained healing through alternative therapies.
E QUINE A SSISTED T HERAPY- D ISCOVERY, S TRENGTH, & H EALING

Elaine, age 58, reported that two years ago, around the time she reached menopause, her voice felt like a mystery. Her vibrato was wider, her usual songs didn’t feel
good anymore, and her flexibility and agility had decreased. Her passaggio, the vocal transition between her high and low voices, was difficult to navigate. She was
frustrated and sad, not knowing if she would ever enjoy singing again. “I couldn’t figure out what I was doing wrong. Plus, I felt I was losing my vocal identity. If I
am not an ingénue anymore, then what am I? How do I find a new singer identity? How do I develop the confidence to explore new repertoire?”
Like other women we interviewed, Elaine wondered if she was doing something wrong, or worse yet, if she wasn’t good enough anymore. The burden of self-doubt
and anxiety impacted everything she sang. There was more going on as well. “During perimenopause, I experienced horrible night sweats which meant very poor sleep.
I am still not sleeping well and rarely sleep through the night. I was on antidepressants, which I thought was because of stress at work, but I wonder if the stress
was actually because of not sleeping. Women don’t get any support for perimenopause symptoms. I also had mood swings, memory issues, and extremely dry lips
and throat. The dry, peeling lips still make me very self-conscious.”
Elaine began working with a highly respected voice teacher who, unfortunately, went the wrong direction with her. The teacher was working with Elaine toward a
sound target ; a specific sound they both expected her to make. She was trying to help Elaine sound like the soprano she used to be, rather than exploring Elaine’s
changing voice and discovering her best vocal function in the present.
Deeply frustrated, Elaine switched to a functional voice teacher who encouraged her to accept the fuller, warmer voice that her postmenopause and post-50
status had given her. It felt like starting over, but she began to accept a more mature timbre, relinquish her younger sound quality, and learn technique and music for
her new, richer vocal identity. It involved undoing layers of tension she had been using to create her perceived tonal identity: her sound from when she was in her
20s.
One thing she didn’t lose was her overall musicianship, noting how much that carried her through the physical changes. “At this point of being past midlife, we
are good at what we do; but I think we forget that. We are only thinking about how we don’t sound like young people.”
Elaine had tried a few different things to help her through her struggles. “I tried Reiki which had no effect on me. I’ve also had lots of massage. But it was my
experience with Equine Assisted Therapy (EAT) that contributed the most to helping me move through my menopausal transitions in both voice and body.” EAT
treatments involve activities with horses to promote human physical and mental health. It’s been used for centuries and has received attention regarding its
application for mental health since the 1990s. [80]
Elaine’s horse is named Chester. “Chester and I are each other’s pets. I am learning to read his moods by watching his body and even the quality of his voice.
Plus, I just love being outside, hearing the birds, enjoying the sun and the weather. With menopause, it’s really easy to let yourself get mentally debilitated because
you are feeling all this stuff that’s changing and you aren’t sure where it’s going. It's smart to find something you like to do that has a physical aspect to it. Like for
me, making Chester’s grain sacks and lugging stuff to his stall. I have to be physically active. Doing an activity I really like - just moving my body - causes me to
move differently, changes my head space, and helps my singing. But also, riding helps my singing with alignment, breathing, breath preparation, and the ability to
release with freedom into things that might be a little scary. It also helps me with rhythm, timing, and tempo. It makes me more flexible - physically, mentally, and
emotionally - as a singer.”
Elaine is also learning how to do a version of horse body work. It’s a gentle and specialized form of massage that requires focus on staying below the horse’s
highly developed danger alert system. She explains, “When you are working on the horse, you have to not trigger his instinct to brace against perceived threat. Doing
this kind of work, and also riding horses, I’ve been not only staying below their bracing instinct, I’ve been staying below my own bracing instinct!”
“Now I am pursuing a certification in Equine Bodywork that requires that I am aware of what my body is doing and what the horse’s body is doing. In that way, I
communicate subtly with horses while riding and taking care of them. The mindfulness of working with my horse has helped me establish more mental balance.
Working with a horse in nature is physical and helps me breathe. I connect back into the grounding and honesty of animals.”
Q IGONG FOR R ECALIBRATION AND F OCUS
Georgia is a vivacious and tenacious woman of 49. She opened her interview with an exuberant “Who wants to talk about dry vaginas?” She is a classically trained
singer and performer, a college-based voice teacher, and mother of three children. She entered menopause at age 46. Her hot flashes got much worse after her
periods stopped, and at about the same time her voice became confusing and unpredictable.
“I developed a weak spot in the middle of my voice, from A above middle C to the C above that. And my upper voice feels like it falls out of the high place; it’s
like it slips away from me. I have always been a flexible singer, but it’s much harder to sing fast passages in the last few years.” She couldn’t sing with clarity in her
midrange unless she sang only on an ‘EE’ vowel. She discovered that, “Singing with the technique that worked for my years of classical singing doesn’t work anymore.
Singing with more of a musical theater technique helps stabilize my voice.” In essence, Georgia is focusing on allowing different sensations of resonance and
registration.
“I also experienced, for a time, that I could still ‘brain-hear’ pitches, but when I sang, different pitches came out! It’s like the nerves wouldn’t talk to the vocal
folds. I wasn’t sure what would come out of my mouth. All of a sudden, I couldn’t improvise harmony. I felt very discouraged.” We have heard other women in
midlife report similar difficulties with mismatched inner "hearing" and inaccurate pitch. In conversations with these women it is clear that this challenge can be
deeply unsettling. It is something we are eager to see researched.
Changes like these are especially upsetting for an experienced performer and teacher. “I would practice and talk to myself, not kindly! And my husband would
say, ‘I don’t think you would talk to a student the way you are talking to yourself right now.’ He was right. You get so down on yourself because you feel like a
hypocrite. You think, ‘I can’t fix myself! I must be doing something so wrong. Who am I to think that I can help other people when I can’t help myself?’ Luckily, I
read a book on performance psychology for singers, and it taught me about my negative self-talk and how to substitute healthier thoughts, no matter what was going
on with my voice.”
Georgia became more centered during postmenopause through practicing qigong. Qigong is an ancient Chinese practice, involving slow, repetitive movements and
focused, meditative breathing. It is thought to have positive effects on the body’s vital energy, or qi. There are studies that show its association with improved
mental health, lowered stress, decreased blood pressure, and improved balance. “Qi can't be measured objectively,” said Shin Lin, a professor of cell biology at the
University of California, Irvine. His studies of qigong have found a boost in both alpha brain waves, suggesting relaxation, and beta brain waves, indicating strong
focus. "It has the dual benefit of relaxing you, but also sharpening your mind," says Dr. Lin [81]
For Georgia, practicing qigong helped improve her voice. “As my voice had become more irregular and unpredictable my mood and stress level got higher. The
qigong helped me quiet my mind while keeping my body active. The more qigong I did, the more my body relaxed. I saw improvement in my voice function. There
were still weird voice days, but they seemed to be less frequent. I was not able to find any medication that helped more than qigong.”
She also told us about other lifestyle choices and diet changes that have helped her with her singing and physical symptoms. She started with the idea that food
is our greatest healer and energy medicine. She consulted with a nutritionist and now avoids wheat flour and sugar. She did an elimination diet and found that she
needs to abstain from tomatoes, garlic, and onions, in order to avoid acid reflux.
Georgia started using a personal steamer to mitigate seasonal throat dryness. Her dryness is worse in the autumn. She schedules performances for when there is
less vocal demand from teaching, and she only sings material that she is comfortable singing right now: musical theater and cabaret.
“I can’t remember a sadder time than when my voice wasn’t working. It’s such a big part of me. I felt alone and embarrassed. I felt like I was the only one
dealing with it. I wish for more of a community to help with this. You might feel alone and embarrassed. Don’t isolate yourself. Talk to others.”
A LEXANDER T ECHNIQUE AND O THER B ODY W ORK
Lindsay entered menopause at age 60, much later than most. Perimenopause can last up to 10 years, and sure enough, Lindsay’s hot flashes and many other
symptoms started when she was 50. She is a life-long singer, with degrees in voice performance, and many years as a professional soloist and chorus member. She
is also a voice teacher and mother of two.
She said that after having children, her soprano voice gained power and richness. In her 40s, she started working with a voice teacher again and studying
Alexander Technique.
Alexander Technique is the practice of mindful learning and honoring the natural, balancedcoordination and poise of the body in both movement and rest. It is a
re-education; a training of the body towards a freer, dynamic body alignment and movement. [82] The practice releases muscles from unnecessary tension and over-
work. It is very popular with musicians, dancers, and actors, among others. There are related health benefits, including lowered blood pressure, reduced neck and back
pain, and improved balance. [83] For singers, if the voice is not functioning freely and efficiently, release of unhelpful tensions through the Alexander Technique can give
impressive results. It may also help by lowering stress and performance anxiety.
One day, Lindsay got a surprise invitation to sing an important solo that included uncommonly high notes at the very top of her range. She had a little over a
week to prepare. It was stressful to have such a short amount of time; her initial attempts were inhibited by vocal tension. Then she remembered that she could use
her Alexander Technique training. Though Alexander Technique does not call itself a “magic fix,” Lindsay applied it to make optimizing adjustments in her legs and
pelvis. This release translated immediately to free her upper range. It served her well for the performance.
Since then, Lindsay has gone deeply into Alexander training and uses it with her students. She says, “I cannot recommend Alexander Technique highly enough! It
helps us disentangle stress and tension from the actual symptoms we may encounter with hormone and age changes. It really keeps your mind and your body
connected. Because they are all connected. The way we think affects how we carry ourselves, whether we realize it or not. It’s not about saying ‘no’ to old, poor
habits; it’s about saying ‘yes’ to the new, good ones.”
After this time of discovery, Lindsay experienced a period of significant disruption and family caregiving. After many years living in one city, where she was
deeply involved in the musical community, her husband’s work transferred them to a different part of the country. At age 50, Lindsay had to start her professional
and personal life over again. At the same time, her mother, who had Alzheimer’s, moved in with them. Her young adult children moved in as well.
After 10 years in her new community, Lindsay is now singing in choral groups and teaching voice to all ages. She shares that, “I’ve been singing alto in one of the
choirs even though I’m a soprano. I’ve found that singing in my low range, more in the chest and mixed registers, has actually helped me maintain my upper range.
Many of my older female students are benefiting from doing this, too.”
“I am not where I want to be with singing. My light, straight-tone choral sound is not as easy as before. I really have to concentrate in order to 'float' in my high
range these days. On the other hand, I do enjoy having a naturally fuller, warmer sound. Even though I’ve lost some of my top range, I experienced improvement with
Alexander Technique, and have gained some notes on the low end. But also, it’s a grieving process—losing abilities that were once easy.”
Though she plans to stay an active singer as long as she can, Lindsay mentioned that she has thoughts about life after professional singing. “I decided to take
acting, improv, and voice-over classes at a local theater company. It was a blast! Who knows, maybe I’ll explore this kind of performing in the future. It was actually
freeing to work with my voice in a completely different performance setting! I recommend exploring your options, including non-traditional health paths. Avoid a “fix
it” approach, which can lead you into another stuck place. You must disentangle stress about the symptoms from the actual symptoms.”
E XPLORING A LTERNATIVE H EALING M ETHODS
The truth is, there's no such thing as conventional or alternative or complementary or integrative or holistic medicine. There's only medicine that works and medicine
that doesn't. [84]
Paul A. Offit, MD, from Do You Believe in Magic: the Sense and Nonsense of Alternative Medicine
Many people turn to alternative and non-pharmaceutical methods once they’ve become fed up with conventional medicine after frustrating ordeals with medical
specialists or negative effects from treatments they’ve received. As singers, we are especially in tune with the healing effects of music, so perhaps we are more
open than many people to the potential benefits of holistic healing. Several of the women we’ve talked with have mentioned using a variety of methods for their vocal
and physical health. A small sampling includes:

Prayer
Holistic and integrative medicine
Yoga
Tai chi and qigong
Meditation and mantras
Cognitive behavioral therapy (CBT)
Cranio-sacral therapy
Massage and myofascial release
Alexander Technique
Feldenkrais Method
Structural body work such as Rolfing and Bowen Technique
Physical therapy and pelvic floor therapy
Chiropractic care
Somatic experiencing therapy
Brainspotting and eye movement desensitization and reprocessing (EMDR)
Expressive arts therapy
Sound therapy
Chakra healing

There are many other kinds of alternative strategies offering a variety of potential results. They may calm the central nervous system, balance emotions, help
with mental focus and clarity, relieve pain, allow the body to heal on its own, and release blocked energy.
It is important to acknowledge the massive benefits we have received from conventional Western medicine as well as to consider the effectiveness of
alternative methods. That way we can explore the best of both worlds in order to achieve our best health and singing.
One thing is abundantly clear: our voice is not like any other instrument. We can’t put it away when we are finished singing. It lives inside us, cradled in our
throat. Because of that, it reflects our physical and emotional health and energy. If we find a tool that brings improved health to our body and mind, it is likely it will
provide benefits for the voice as well.
There has been a revolution in how we perceive the body. What appears to be an object, a three dimensional anatomical structure, is actually a process, a constant
flow of energy and information.
Deepak Chopra, M.D., Hindi-American Author and Health Advocate
Chapter 8

FINDING YOURSELF ON THE OTHER SIDE

There comes a time when it is no longer wise to focus on and keep trying to do what you can’t do any longer, and better to turn your attention to enjoying what you
can do.
...focus on adapting to what’s happening in the present rather than resisting the changes and living in the past. [85]
Martha Howe, A User's Manual for the Aging Voice
It doesn’t sound like much fun, does it? To adapt rather than to resist. How can a person, whose vocal identity was established decades ago, even consider giving up
on the quality of her younger voice? The answer is that sometimes we simply don’t have a choice. Sure, if the changes are small and gradual, we may be able to
gracefully bend ever so slightly with the changing tide. However, when the changes come at us like a raging river or even a tsunami, we may feel lucky to survive.
The women in this chapter show us how they recalibrated their voices after change. They tell us about the resilience needed to adjust. These women, all dealing
in some way with becoming mature singers, can help guide us toward redefining our singing-selves if needed.
M IXED E MOTIONS ABOUT C HANGES
Jessica, age 67, was an early childhood and elementary school music educator as well as a professional classical soprano. “Singing through the day with my students
kept my voice in good shape. Plus, it was a joy!” The onset of menopause caught Jessica by surprise because she didn’t have many symptoms. “My periods were a
challenge. They were pretty heavy. And then, when I was 52, they just – stopped.”
Around the same time, Jessica noticed that her singing mid-range seemed to be muffled, less resonant. It didn’t occur to her to associate it with hormonal
changes. “I had to be very careful how I negotiated that part of my voice.” Lip trills and other similar exercises helped maintain her singing, but she and her teacher
decided on a strategic plan to avoid that range as much as possible. “My song choice had to follow what my voice was doing. And it still does.”
One thing Jessica mentioned is that sometimes she feels down. She said, “For me, the biggest disappointment in aging is becoming tired, not being able to do all
the things I want to do.” She seemed a little sad in the interview when we talked about her lower energy level. “I equate being tired with being depressed. Is that
strange? I don’t really have strategies except to rest a bit for a couple of days, and then I perk up. My gynecologist pointed out to me that I really am very busy, and
that it might be natural to be tired at times. She’s probably right about that.” Jessica added, “It’s important to be aware of how you are feeling.”
Jessica shows understanding that false positivity can hold us back. According to Petra Borzynski, vocal and cognitive behavioral coach, “Reframing ‘negative’
emotions requires an awareness of what you are feeling. This is often the hardest step. Emotions are trying to tell us something. They are not the problem, but our
actions in response to those emotions can be a problem. If we cheerfully deny our negative emotions, we inadvertently refuse ourselves an opportunity to explore
them and take appropriate action to move forward and grow.”
Opera singer Gabriella is processing negative feelings as well. She told us, “I have struggled with depression off and on for all of my life. When I am on the
downward path my singing shows it. I am just now, at age 70, contending with the decline of my singing. Singing has been the unifying thread of who I am all these
years. It has kept me sane through all the struggles of life. Singing has provided thrills and triumphs enough to make me love living. Over the years I chose repertoire
that helped me temporarily escape my mundane existence. My truest friends are my singing colleagues.”
Gabriella has sung all over the world in a wide variety of genres, from professional opera to women's barbershop quartets. She has performed leading roles in
musicals, as well as placed first in the talent portion in an international senior pageant. She currently has a regular church job, where she sings in most styles from
early sacred music to contemporary praise. She performed her last full-length solo recital at age 68, and made her last solo recording at age 69.
Regarding her singing longevity, she said, “It was just practice, practice, practice. Paying attention to focus, placement, support, and pitch - that kept me in
shape. I have been on a miniscule amount of HT for the past twenty years, and I believe that has helped me keep my singing.”
Though she feels that her voice got better over the years, lately things have changed. Her extreme high notes, which were easy in the past, now take enormous
concentration. She said her vibrato is slower, sometimes the pitch goes a little flat without her knowing it, she needs to breathe more often, and isn’t able to hold
some notes as long as she used to. Overall, her vocal stamina is not what it was.
Gabriella went on to say, “It is making me extremely sad to know that I can no longer perform at the level I am used to. But then, aging in general is making
me extremely sad, as friends and family members die, and as I come to grips with the awful truth that all I have accomplished, experienced, and dreamed of will
someday slide into oblivion. No shame or bewilderment, but I Do Not Approve!”
Gabriella experienced sadness and depression just like many older people. In 2009, the National Alliance on Mental Illness reported that 6.5 million of the 35
million Americans over the age of 65 suffer from depression. [86] Women accounted for 66% in this study.
Though making music may have a role in improving mental health, it isn’t a cure-all. Anyone who experiences periods of ongoing depression should not delay in
finding professional help. A good place to start is by discussing it with friends, family, a spiritual mentor, a primary care doctor, or mental health specialist. Geriatric
counselors and social workers can provide physical and psychological assessment services for older adults. They can also provide counseling or help find solutions for
anything interfering with a senior's quality of life.
I MPROVEMENTS TO THE H IGH R ANGE
Ruth, at 77, is a gentle woman who enjoys singing in her church choir. She has sung in other choirs off and on throughout her life, including the Sweet Adelines, an all-
women’s barbershop choir. Her professional life was in social services and administration.
Ruth took HT for a number of years following menopause in her 50s; but when she was diagnosed with breast cancer, she had to discontinue it. Ruth is now
cancer free and is remarkably upbeat about that health scare. “You play the hand that’s dealt. I believe that. I try not to make a big deal over things. I just move
forward.”
After menopause, Ruth’s voice had a few issues, including occasional raspiness corresponding with a diagnosis of reflux, which she continues to treat. Since her
late 50s, she feels her voice has been mostly stable, but breathing fully for singing is harder. “I really have to think about ‘filling up’ these days. It doesn’t happen as
naturally as it used to.” Ruth went on to say, in her high, light speaking voice, “I sing in a choir twice a week. There are times when I sing better than others. I don’t
have a trained voice. I’ve never had any training. Maybe I should take some lessons!” Ruth reported that her voice has gone higher instead of lower, and that she has
lost some low notes. “I had always sung alto in choirs, so it’s been a surprise to discover my singing range has actually become higher. I am now comfortable singing
second soprano. While I can sing higher now, these higher notes must be sung loudly—I cannot sing them softly.”
There are some singers, like Ruth, who unexpectedly find that singing higher feels better than before. When a woman says her voice is getting higher, she can
mean two different things; a gain of actual pitches at the high end of the voice, or singing high is easier and more desirable than it used to be. The latter means that
being comfortable in a higher range, or higher tessitura, has been the result of either voice change and/or improved singing skill.
In two doctoral dissertations, The Effect of Menopause on the Elite Singing Voice byBarbara Fox DeMaio, and The Professional Female Singer and Career Longevity
by Anne Elise Richie, the authors noted that several women they interviewed changed to higher singing parts postmenopause. [87] , [88] This seems to go against
common wisdom as well as voice research. Research is important, but most studies on the aging female voice have been done on the speaking voice and only show
us an average. The studies are generally in agreement with each other that speaking pitch tends to lower with age for the typical woman. That said, it isn't clear how
a slightly lower average speaking pitch might relate to a specific woman's singing voice.
We have some theories about why some women might find their singing voice getting higher. One is that if a woman begins hormone therapy, whether for relief
of menopausal symptoms or because of medical issues, particularly after an extended period of reduced hormones, hormone therapy may occasionally bring back
some lost vocal abilities. In the case of Barbara Fox DeMaio and some of the women she studied, adding hormone therapy after the voice had lost top notes brought
some of those top notes back. They also experienced ease in their higher range, similar to when they were younger.
Another factor that needs to be considered is how the voice is being used. Oftentimes speaking voices cover a limited range of pitches. Since muscles are at the
foundation of voice production, they get a workout every time a person talks. The muscles that dominate for speech can become more developed than the muscles
that dominate for the higher range that some use for singing. People like Ruth who worked in social services, and others who have careers calling for substantial
voice use, may have been required to talk all day. Commonly their speaking voice use decreases significantly when they retire from their careers. This can lead to a
recalibration of the balance in the muscles of the voice. The new balance may be experienced as improved ease in singing, especially for high, light, and rapid notes.
On the other end of the spectrum are older women who choose to speak high enough that they stay above the range that requires engaging the low voice. If they
instinctively or purposefully avoid singing and speaking in the low range, the muscles that produce the low voice could become weaker from lack of use. The result
could be difficulty singing in the lower range, because high voice muscles are favored in the balance. And in this scenario, sometimes the lower register transition
becomes unstable and difficult to negotiate.
We typically advise that women exercise and use all of their singing range. Doing this should help avoid an imbalance in the two sets of muscles that support our
ability to sing both low (below the music staff) and high (at the top of the staff), no matter the voice type. Furthermore, voice researcher Dr. Ingo Titze suggests
that stretching the voice throughout the range serves to preserve not only the muscles, but the elastic, resilient materials found in the tiny layers that overlay the
muscles. [89]

D EALING WITH V OCAL F OLD I NJURY

At age 66, Mickie is mourning the loss of her once easy singing voice. She trained as a singer in the English choral tradition and had wonderful experiences in choirs
under the direction of fine conductors. “I could fly high on those descants!” she remembered.
In her late teens, her professional chorus was scheduled to perform at Carnegie Hall, but she ended up getting married to her husband, a clergyman, instead of
singing that concert. She joked, “I gave up Carnegie Hall for love!” She built her life around singing for the churches that he served, volunteering as needed as a choir
member, cantor, and choir director.
“I don’t recall any vocal issues until Christmas when I was 49 years old, about five years after menopause.” On Christmas Eve she had a solo, but she was
hoarse from illness. “Despite my cold, I sang anyway. It was not the first time I had sung with a cold," Mickie said. "It was going ok until I sang the high note at the
climax of the piece. I felt something pop in my throat. After that, I lost my upper range and my voice didn’t feel the same.” She did not see a doctor, but regrets it.
“I wish I had the fortitude at the time to have found out what had gone wrong, and to find out if there was anything that could have been done for me.”
Soon after, her husband was promoted to a position that did not include serving a congregation, so she didn’t have a church home to sing in and stopped singing
regularly. “Eventually I saw a voice teacher because, when I started vocalizing again, my vibrato had become horrendous. We worked with voice therapy exercises and
she asked me to sing in my chest voice. It didn’t have to be a pretty sound, just a sound. I burst out weeping when she made me sing those low notes. She also had
me sustain pitches as long as I could. The lower I went, the more I went into my chest voice, the more the tears were coming out of my eyes.”
Using “chest voice” can cause some women to have anxiety because it clashes with their personal vocal identity. Sopranos in several vocal traditions are taught
to avoid their low voice in order to supposedly preserve their upper tones. Then, if they study with a voice teacher skilled in working with older singers or a teacher
who has had vocal function and health training, they may be taught the opposite. Current vocal pedagogy advises developing low and high voice for optimal singing.
Fears may come up as they work with unfamiliar sensations and techniques that contradict their previous training and vocal experience.
Though Mickie sings hymns in the church they attend now, she still grieves the loss of her easy, soaring high voice. She knows that her voice is warmer, lower,
and more vibrant, her pitch is accurate, and she doesn’t have a wobble. But her voice fatigues more easily.
Mickie’s feelings about her voice run deep; “My relationship with God and my voice are so intertwined. I was brought up by my wonderful choral directors to
understand that we are doing this for the glory of God. It’s not performance. This is worship. For me to not be able to offer my best, or, for my best to have changed
to something that is no longer my best – I struggle with that. It is a spiritual crisis and it affects my sense of worship.”
The reason for the sudden voice incident that happened on Christmas Eve was never determined, but it may have been a vocal fold hemorrhage. It is impossible
to say for certain. However, others who have experienced a sudden hemorrhage use similar terms to describe the feeling. What is clearly evident, and what so many
of us have experienced, is that relinquishing our vocal identity can be painful. The hurt is even greater if the quality of singing is tied to a spiritual practice.
W HAT IS A V OCAL F OLD H EMORRHAGE?
A vocal fold hemorrhage [90] is a sudden injury that results from bleeding from one of the tiny capillaries in the vocal folds. It is similar to a bruise, and like a bruise,
results from trauma to the vocal fold tissue. The trauma can happen from a vigorous vocal maneuver, such as a loud shriek or yell; a violent vocal outburst, like a
loud sneeze or cough; or attempting a loud singing task when the vocal folds are fatigued or compromised, such as having a scratchy voice from being sick.
Singers who have experienced vocal fold hemorrhage describe their symptoms in the following ways: a sudden change or loss of vocal function, sudden vocal
instability or hoarseness that develops very quickly. It may feel like something “happens,” like a click, in the laryngeal area. Generally, there is no pain.
If a singer notices this type of sudden change in the voice, the first thing to do is to stop voice use entirely; that is, be completely silent. The next thing to do is
to get an appointment with an ENT as soon as possible.
 If there is a hemorrhage, then, unlike with vocal nodules, complete voice rest needs to be continued until the bruising is gradually reabsorbed into the tissue. This
is verified by a follow-up examination. Total voice rest is critical, because ongoing voice use may cause a repeat bleed or long-term scarring of the vocal fold tissues.
After healing takes place, usually within about 2 weeks, singing can be gradually resumed.
As for other treatments, steroids are sometimes prescribed following a vocal fold hemorrhage, but some practitioners do not recommend them in this situation.
Microscopic surgery may be considered if a person has a repeat vocal fold hemorrhage or has a tiny blood vessel on the vocal folds that seems vulnerable. In some
cases, singing voice therapy may be recommended as part of recovery.
Keep in mind that though vocal fold hemorrhage may seem like a daunting injury, if diagnosed in a timely fashion and followed by appropriate voice rest and
follow-up care, it should result in an uncomplicated recovery.

M INIMIZING THE R ISK OF V OCAL F OLD H EMORRHAGE

There are things that a singer can do to minimize the likelihood of having a vocal fold hemorrhage, including:
Maintain good, basic voice hygiene: stay well-hydrated, don’t speak against loud background noise, monitor overall voice use, and warm up and cool down
after voice use.
Don’t sing when the voice is impaired from illness or when vocally fatigued.
Keep the voice in good technical shape, and get training for special demands on the voice, such as high belting, stage screaming, or extreme vocal
techniques for certain styles.
For women who are menstruating, the voice is more vulnerable several days before the menstrual period and during the first few days at the beginning of
the period. They shouldn’t push the voice during this time.
Unless medically indicated, active singers should avoid frequent use of drugs that compromise coagulation; including non-steroidal anti-inflammatory drugs
(NSAIDs: ibuprofen, naproxen sodium, etc., and aspirin). Consider use of medications carefully as they relate to the voice.
Some natural supplements can affect blood coagulation, including garlic, gingko, ginseng, ginger, and fish oil. Their use should be discussed with the voice
caregiver.
Singers who perform frequently should have a baseline record of their vocal folds and have periodic examinations to track changes.
A TTITUDES FOR M OVING T HROUGH C HANGES
Denise, now 61, was an active classical performer. When one of her children became seriously ill, she stepped back from performing to take care of him during his
recovery. At the same time, her teaching career began when friends from church, women in their middle years, asked for help with voice symptoms they were
experiencing. “When you ask me if I had heard anything about voice change associated with menopause, the answer is yes – my students’ experiences taught me! In
addition to voice help, the women appreciated the chance to talk about menopause in general. I am grateful to have shown a lot of women how to sing well into later
life. But they must work at it between lessons! Once a week is not enough.”
Once her kids were grown, Denise returned to performing actively and found her voice had filled out during her time away from the stage. “My voice felt just
great in my 40s! And although I lost a little at the very top of my range, just a couple of notes, the menopause transition didn’t really change my voice much.” Now,
six years past menopause, she says that she still performs, and she is “charting the journey of my aging voice. Because of aging, some things are harder now and I
have more acid reflux. I’ve lost a few high notes but have more on the lower end. I need to warm up really well or I get hoarse. I still have vocal flexibility but have
to work very hard to maintain it.” She made some adaptations, such as exploring different music genres. In general, she doesn’t lower the keys of her old songs but
chooses to learn new music instead.
On the other hand, another woman we talked to struggled with a medical condition that robbed her of having a reliable voice. She found that at first she couldn't
face returning to performing, knowing it would be less than her best. She told us, “I took a sabbatical from singing. But after all of that time off, I ultimately went
back to singing and cantoring because I realized that it wasn't really not being able to sing that had stopped me. It was about not being able to sing at the level I had
come to expect; it was my own pride. I decided music was too important, and that it was really about the message, the lyrics, and the emotional impact at the heart
of performance. I have accepted that I can't do what I used to do but that I can still have an impact and am awfully glad singing is once again at the heart of my
life. Acceptance of my own foibles and flaws has been very freeing.”
Singing from our 60s and beyond is not only possible, it can be embraced. Maintaining the voice requires recalibration of expectations and skills. And, of course, a
commitment to reasonable, but not overwhelming, vocal exercise. Doing so will help keep the voice in balance. If possible, work with a teacher, sing with a supportive
choir, or find your own special support network. You don’t have to go this alone!
It is music and dancing that make me
at peace with the world,
and at peace with myself.
Nelson Mandela, South African Social Rights Activist,
Politician and Philanthropist
Chapter 9

SINGING INTO OLDER AGE

There are far more old people than there are ‘old’ voices. [91]
Günther Habermann, Voice Researcher
People age in two ways: chronologically and biologically. Our chronological age is the number of years we have lived since taking our first breath. Our biological age
reflects how old we seem to be. [92] For many of us, these ages don’t match. Why? Genetics are a part of it; there are variables regarding how our genetics are
“expressed.” Parts of our DNA get turned on or off by our lifestyle choices, physical health, and our biochemistry is changed by our thoughts and beliefs. [93]
Researchers have shown that voices have a chronological and biological age, too. [94] Well-maintained and healthy voices preserve youthful qualities longer. The
factors influencing biological vocal health are the same as those for the rest of the body: expressed genetics, lifestyle choices, and physical health. Additional
influences include our quantity of voice use, voice health history, and current vocal fitness. [95] It’s encouraging to know that at least one study shows that singing,
including participation in choral groups, is associated with a younger-sounding voice. [96]
P HYSICAL C HANGES TO THE A GING V OICE
Changes in the respiratory system from aging, which can begin as early as our 30s, are likely to eventually impact our singing. [97] Over time we lose elasticity in the
cartilages of the ribs as they ossify, and lung tissue becomes less pliable. For these and other complex reasons, we can’t get as much air into the lungs when we
breathe. For average, healthy, non-singers, it’s not an issue for everyday voice use. But for singers, it can become more challenging to maintain the kind of air
pressure we need to sing loudly, especially for long phrases. [98] Respiratory training can help, but older singers may simply need to breathe more often.
The structures of the spine and neck may change for many reasons. What is considered effective and flexible alignment for a younger body may no longer be
comfortable or even possible as singers age, but that doesn’t mean we have to stop singing. Adaptations can be made, such as sitting down while singing or using a
walker or the back of a chair to ease the effort of standing.
Abdominal and back muscles provide structural support for singing and help with the stability of the larynx. General fitness can help overall singing.
The small structures of the vocal folds also change, though less so with continued use. [99] The epithelium, the “cover” that slides over the lower area of the
vocal folds, changes so the voice may feel stiffer. [100] The thin layers of the vocal folds that are underneath the epithelium gradually change structure and become
less elastic. The deepest, muscular part of the vocal folds loses mass. Arthritis can also affect the tiny joints of the larynx. If these joints become stiffer, then the
voice may feel sluggish and there may be particular difficulties with upper range. [101]
The vocal tract gradually changes shape over the years due to bone and muscle changes in the jaw, mouth and throat. This means that our resonance, and the
way our resonance feels to us, changes. [102] Some women report increased richness and depth to their singing. Many women report needing to figure out how to work
with these changes, not against them.
Additionally, nerve transmission speed can slow down as we get older, which can impact how fast we are able to articulate words. To help offset the problem,
keep the tongue, jaw, and lips nimble. Along with singing, two good practice ideas are to recite tongue twisters and to read aloud for several minutes a day. [103]
L OWERED S INGING R ANGE IN A GING V OICE
One of the most common issues women experience is a permanent lowering of the comfortable singing rangeof their voices. It can be baffling for a singer to find
she might belong in a different voice category, or that she may no longer fit into one of the treble categories. For women who want to keep singing, the best plan
might be to harmonize on lower parts, change the key of the music, or join a vocal improvisation group, like Circle Singing groups where singers can usually sing in
their most comfortable range.
One of the women we spoke with made a dramatic move in her church choir. Theresa, age 81, participated as an alto for most of her life, but things changed.
She now proudly sings with the baritones and basses. Theresa told us, “When I was about 75, I wasn’t able to reach the alto notes higher than A above middle C.
Some of the songs have alto notes that are higher, and I could no longer hit them. I skipped tenor because tenors have the ability to go higher than I can! A voice
teacher in the choir encouraged me to ask the choir director if he would be alright with me singing with the baritones. He was quite fine with that! Sometimes he
says, ‘OK, men... I mean basses.’ I don’t mind that he says ‘men.’ I don’t care, it doesn’t matter to me. I just transitioned to what enabled me to keep singing with a
group I love.” Then she chuckled, “I am 81 and not chasing the fellows, so maybe that makes it more comfortable for them!”
Accepting that it's not uncommon for the voice to get lower with age is an important strategy for women who want to continue finding joy in singing and
experiencing the benefits from singing.
R ELENTLESS V OCAL T RACT D RYNESS

D RY M OUTH AND T HROAT [104] [105] [106] [107]

Dry mouth, dry throat, and thick mucus are caused by problems with the saliva and mucous glands. When we age, there is a reduction in the number of tiny glands
that produce mucus for the larynx, resulting in fewer secretions to support the “veil of mucus” on the vocal folds. The vocal folds produce sound more easily when
there is slippery mucus bathing them, so reduction of mucus is noticeable. The amount of saliva in the mouth can also decrease in some people as they get older due
to natural changes, some medications, or medical conditions. Medically, dry mouth is called xerostomia and dry throat is called xerophonia.

Causes of increased dryness include hormonal changes, aging, breathing dry air, and certain medications, including over-the-counter cold remedies. Strategies
that can help include drinking plenty of fluids, increasing humidity in the environment, and using handheld saline nebulizers. Sugar-free lozenges and special mouth
rinses meant for dry mouth are also suggested.

Singers are highly sensitive to the feeling of a dry mouth, throat, and larynx. It can be painful to sing when a woman experiences an extreme episode. Betty, now 74
and a life-long singer, struggles with this problem. She was on hormone therapy from ages 35 to 61 due to an early hysterectomy. At age 61, her doctor decided she
shouldn’t be on HT anymore because she’d developed high blood pressure. She went off of the HT but her blood pressure didn’t return to a normal range, necessitating
medication. Unfortunately, blood pressure medications can cause dry mouth. [108]
She began suffering from severe hot flashes after age 61 so she went through a clinical trial of more HT before her doctor determined that her elevated blood
pressure was not caused by HT, but rather was caused by taking ibuprofen for the pain of osteoarthritis. Incidentally, studies show that any benefits to heart health
from HT may be reduced if a woman is also taking ibuprofen regularly. [109]
“Finally, my hot flashes are almost gone now at age 74! But dryness everywhere is terrible, including my lips. There is a real lack of vocal dependability, even
when I am rested, hydrated well, and sing every day.” These days Betty doesn’t feel like singing much and told us that she’s “feeling now that maybe it’s time to just
age out of choir. I was a first soprano; but for now, I am singing second soprano. I don’t really have more low notes; the top range just isn’t very strong.”
Betty’s story reveals an interesting and complex puzzle, especially because she mentioned also being on thyroid medication. Just as thyroid disease can mimic
perimenopausal symptoms in midlife, in later life it can masquerade as aging symptoms. In older people, symptoms such as mental slowing, loss of energy, dry skin,
and even hearing loss can be symptoms of hypothyroidism. [110] These symptoms might be chalked up to aging and get overlooked. In addition, thyroid dysfunction can
cause noticeable voice changes, such as loss of range and cloudy tone. [111] It’s important that medical caregivers be alert to potential thyroid dysfunction in older
people and that therapeutic doses of medication, or effective alternative measures, be maintained for best overall health as well as vocal health.
For now, Betty is hanging in there with her choir. She loves the companionship and the mental and musical stimulation it provides. One possible solution for the
problem of reduced range would be if her director would allow her to move between parts. Perhaps Betty might be better served by singing alto on some songs, and
second soprano on others. One choir director coined the term “trans-sectional singing” for people who move between parts. Being part of that “section” can be very
helpful for aging singers.
H OW M UCH V OCAL E XERCISE IS THE R IGHT A MOUNT
Using the voice will keep it more youthful, but finding just the right “dose” is important. The voice fatigues more easily due to neuromuscular changes so we shouldn’t
overload it. On the other hand, resting a healthy voice because of worries about overdoing it, lack of opportunities to sing, or social isolation, will cause further loss of
neuromuscular function. While we don’t need to prepare to “run a marathon” with the voice, we do need to “take it out for regular walks.” People who live alone need
to exercise their voices more than those who have the opportunity to socialize. Even talking to the television or to a pet will help keep the voice stronger.
A researcher in England, Rebecca Moseley-Morgan, did a long-term study of female classical and choral singers who are well past menopause. The women
followed a 20-minute minimum, targeted practice regimen every other day of the week. Over a six-year period, Moseley-Morgan found that the women showed
improved respiratory function and vocal range, and increased power and stamina. They also had improved evenness of tone and sang with less effort. [112]
Her study shows that singers would do well to add a few sessions of mindful singing homework in addition to their weekly performances, rehearsals, or lessons.
Singing requires over 100 muscles to function in exquisite coordination. [113] So, it is important that we do a regimen that includes several types of exercises and
tasks in order to keep the voice in good balance. There is no one magic exercise that will do the trick.
Paulie is an 81-year old retired psychotherapist and former athlete. Paulie didn’t actually start singing until she was 60 years old! Prior to that, she was a trained
pianist, dancer, and physical education teacher before earning her PhD in psychology. She understands the discipline and curiosity required to learn and train brain
function and coordination. Paulie revealed, “Movement and the routine of training have always been my safety net, my self-therapy to survive a very abusive childhood
and parents.”
Paulie continued, “While I’ve had severe chronic pain, I’ve always enjoyed a robust immune system. I’ve had several sports injuries, resulting in three spinal
surgeries, two knee and two hip replacements. My last back surgery was three years ago, and it wasn’t until that last major back surgery, around age 78, that my
pain let up considerably.”
After Paulie’s divorce from a long marriage, she moved to a new city to live with a friend. Her friend is an active singer who introduced Paulie to groups to sing
with. At age 60, she decided to start taking private voice lessons. “It was a great new beginning for me. I had no younger voice to compare to, so I couldn’t complain
about my voice getting older!” She said that singing has been an antidote to pain. Considering Paulie’s many injuries and surgeries, this is a remarkable testimony to
how singing can have a strong effect on the brain and perception. She’s been singing the alto part in choirs ever since.
That year, in addition to the divorce, the move, and building new community involvement through singing, she also needed a hysterectomy: Paulie experienced a
prolapsed uterus. This condition may occur when the muscles and other supporting tissues of the pelvic floor weaken and can no longer provide support for the
uterus. As a result, the uterus can slip down into the vagina, or, in Paulie’s case, protrude out of it. “My uterus fell out of me one day while I was on the toilet. As I
was wiping myself, I thought, I’m not supposed to have balls! What on earth is going on?” She had an emergency hysterectomy and had one ovary removed, “...but
they couldn’t find the other one.” She was put on estrogen after the operation. “But I went off of HT due to some health scares that were being propagated in the
early 2000s.”
“I am very focused,” Paulie said, “and practice consistently with a lot of joy. I have improved a great deal vocally. I am a life-long student who knows how to
pursue interests; and since I could read music and appreciate all kinds of music, I enjoyed becoming part of a choir in order to form a new family and a new way of
‘belonging’ in my new life. I now sing in two regular choral groups and participate in a city-wide drop-in group in the African-American tradition. My voice has gotten
better and better these past twenty years. I don’t have a beautiful voice, but it is very serviceable in an ensemble. I sing on pitch and with good energy. I take time
off when I am not well or recovering from surgery and get right back into it.”
Recently, Paulie went through another major life transition when she moved into her own apartment to live alone for the first time in her life. It was very
stressful. She lost her short-term memory, her concentration began to decrease, and she had several falls and minor car accidents. Her walking gait was off and she
felt disoriented much of the time. She began working with an integrative health specialist who made recommendations to help her get her memory back, clear her
brain fog, and regain her balance. Paulie thought about the potential treatments carefully and decided to proceed with individualized hormone therapy and other
alternative treatments. In Paulie’s case, during that 6-month stretch she recovered her memory, her brain fog lifted, and her balance and gait improved. She has the
light back in her eyes and feels more like herself again. And she’s still singing.
T REATING THE W HOLE P ERSON
Paulie has significant insight into medication from her background as a psychotherapist and her extensive experience with medical issues and aging. Her perspective is
that “The medical profession has, by and large, brushed off pre-and post-menopausal and aging women and sent them to psychologists. The ethics of my profession
state that even psychologists and psychiatrists are supposed to help patients find physical symptoms first , before treating them with drugs. In other words, they are
supposed to refer them to appropriate medical doctors first. This doesn’t happen like it should with midlife, menopausal, and aging women because few doctors really
know the physical reasons for all of our complaints. Women, during my lifetime and before, have been given drugs and all sorts of cruel remedies for depression,
anxiety, rage, feelings of craziness, hyperactivity, hypersexuality, low functioning sexuality, and spaciness. I don’t believe drugs should be given without also
recommending therapies for emotional and social well-being.”
Paulie’s story shows that learning something new takes consistent work, realistic expectations, and a love of learning. Thanks to singing, Paulie has experienced
tremendous joy and community connection for the past 21 years. As she mentioned several times, she knew she’d have to work at it and welcomed the new
challenges. She is also an example of someone who utilizes both western and alternative medicine, integrating what her research and her intuition tell her to do.
T ROUBLESHOOTING C OMPLEX I SSUES
Dorothy, who is now 78, studied singing with respected classical voice teachers when she was a young woman. She sang opera roles in regional opera houses in the
United States. During midlife, however, she took a 15-year singing hiatus. Dorothy explained, “There was a time when I stopped singing. I don’t really know why. I
think it was… well, my father died, and I think there was something that just shifted in that whole dynamic. Then I met my husband, and I just basically, well, I kind
of gave up.”
When she returned to singing, about 10-12 years ago, Dorothy found that her voice had several problems. “I couldn’t tell what was causing the problems. Was it
hormones? Technique? My body?” Because she didn’t experience her singing voice through midlife and menopause, she was taken by surprise by its condition after the
long hiatus. “There were so many things to consider as sources of my vocal issues. Very difficult to unravel all that!”
One teacher taught her to use exercises designed to improve access to the thin edge of the vocal folds. Dorothy said, “It seemed to help, plus we worked on
incorporating chest voice, which I was avoiding. In spite of improvements, later on I started having pitch problems. Then last year, I started having trouble with the
voice quality in my middle voice, so I went to an otolaryngologist who treats singers. He told me things looked like he’d expect them to look at my age. In my mind,
that meant my vocal coordination was wrong and that’s why I couldn’t sing on pitch. I might have reflux, so I’m treating that. But I am very determined to figure out
why I am having pitch problems.”
There is a condition that is common enough in older voices that it could explain why Dorothy’s doctor said that her vocal folds looked like they did, although only
her doctor would know. As we get older, the muscles of the body tend to lose mass and strength; this is called sarcopenia, or atrophy. The vocal folds are no
exception, and in some cases, the loss of underlying muscle tissue is so pronounced that the edges of the vocal folds begin to "bow" out in the middle, causing a gap.
Because the folds cannot come together completely, the sound can be breathy and weak and loses its carrying power. Singers might start to squeeze the muscles of
the larynx to try to make a better sound. Therapeutic voice work can be helpful in dealing with the tension. Typically, a speech therapist or a voice teacher who has
trained in vocology would focus on improving vocal fold muscle bulk, and there are other treatments that can be discussed with a laryngologist.
Dorothy now teaches singing and said she sings a bit in her students’ lessons and works on her own voice a little every day. “Next I’m stepping up vocalizing to
build some stamina. I also started biking and walking for aerobic capacity. I pick funny songs to sing so I don’t have to worry about pitch while I am rebuilding my
technique. In general, I am very self-critical, which doesn’t help. But I’d like to feel better about my pitch and maybe try some other genres of music.”
E FFECTS OF M EDICATIONS ON THE V OICE
Dorothy had to stop the interview to cough. “Sorry. I’m coming out of an asthma attack. The asthma medications I am on don’t seem to affect my vocal folds, but I
know that there are some drugs that might cause voice problems.”

A STHMA AND S INGING [114]

Medications for asthma help with breathing, which is first and foremost in importance. People with asthma who sing should ask their doctor about the potential
effects of these medications on vocal fold tissue and what the best techniques are for taking them. Inhaled corticosteroids may cause vocal disturbances in asthma
patients. Information about side effects on the voice from these medications and many others can be found on The National Center for Voice and Speech website .
Coughing has been a very big issue for Dorothy: she has had several extended coughing spells. No one has been able to figure out what the cause was, although
her acid reflux might have been a factor. Coughing repeatedly will irritate the vocal folds so that they swell, making it difficult for them to function well. Even though
the episodes have calmed down, she worries about how coughing may have affected her vocal folds. She remains sensitive to how her throat feels and takes
medications for acid reflux.
She also takes Mucinex ® for her dryness. Its main ingredient is guaifenesin, which thins mucus and can be very helpful. She admitted that she doesn’t like to
drink water – that it’s hard for her to get much down, but drinking through a straw helps.
Despite all of these issues, Dorothy is determined to improve her singing. She said, “I think that if I worked steadily and continually with somebody who knows
something about the - I don’t know what to call it - the leftover voice. I think that I would be happier, but this is always something that is in my heart, that feeling
of not having actualized what was possible. So that makes me sad.”
C HANGES IN H OW S INGERS P ERCEIVE T HEIR V OICES
One reason we need to re-coordinate how we sing as we get older is that there can be a change in how we feel singing, changes to the way we sense our voices
through our bodies. When we sing, we are guided by physical sensations at least as much as by hearing ourselves. You could say we “feel-hear” our voices. We feel
through our bodies. When we sing, we are guided by physical sensations at least as much as by hearing ourselves. You could say we “feel-hear” our voices. We feel

our sound vibrate in the bones and tissues of our head, chest, and mouth. These sensations can orient our singing in helpful ways. In addition, our ears pick up and
process sound waves that emerge from our mouth, but the way we hear ourselves in our own ears is not exactly what others hear. That’s one of the reasons we are
often surprised by how we sound on recordings, aside from poor quality recording devices.
Two things can potentially affect how we feel-hear ourselves when singing and speaking. First, there are changes in our sensitivity to the buzzy sensations of the
head, mouth, and chest. It begins to decrease as a natural part of aging. [115] So, even if we are singing in a way that still produces effective resonance, the tiny
sensory conductors in our bones, cartilage, and skin simply don’t respond as well. Less sensitivity may make it harder to perceive how our voice is functioning,
including our tone and registration. [116]
Therefore, some older singers need to be careful not to “manufacture” missing sensations by doing things like tensing the jaw, tongue, or the muscles of the
face. These strategies only masquerade as feelings of resonance. More importantly, even small tensions can make singing more difficult and may produce a less
pleasant tone quality. Our new normal as we get older is that we may naturally feel our singing with less sensitivity.
The second issue is hearing loss. For those who experience it, lowered sensitivity to sound will affect how our ears process the tone we are making. Hearing aids
are a wonderful tool, but at least when we first start wearing them, they may also complicate how we feel-hear our voices. There may be a learning curve as the
singer and her brain adapts to hearing-aid assisted singing. If possible, working with a voice teacher who has experience and joy in working with older voices should
help with negotiating these changes.
D RIVEN TO S ING
Francesca is a tiny and tenacious 83-year-old. She has retired from professional singing and choral conducting and, except for a few years scattered throughout her
long life, is still teaching singing after 53 years. She also volunteers as the conductor for the community choir at the independent living facility where she lives.
Francesca’s first surgery was when she was 43, a hysterectomy done for dubious, non-medical reasons. "I mentioned to my gynecologist that the week of my
period I felt amazing--grounded, strong and happy, but that the other 3 weeks I felt like 'the molecules that were me were floating all over the place, unconnected.'
His solution was to take my uterus out, and I just did what he recommended. I knew nothing."
Several years later, her ovaries were removed. At that point, Francesca was put on HT. But soon after, her doctor discontinued it and switched her to
testosterone - she doesn’t remember why. But after a month on testosterone, she noticed her singing voice was lowering. Francesca took herself off of testosterone
when she drew a connection between it and her lowering singing voice. [117]
She added, “In addition, I needed two hip replacements and two hip revisions due to osteoporosis and continue to have major stenosis in my spine. I have spent
quite a bit of time in physical therapy, using various medications, acupuncture, and contemplation to manage the pain. However, I kept singing through all of it. I lost
some vocal power, the low range disappeared, my sound thinned out, and it all became a bit unstable. But I kept the lilting quality of my voice and much of my upper
range. I began studying off and on with a wonderful voice teacher and was astonished at how much more secure I felt with a different sort of exercises, mindset,
and practicing routine than I was used to doing.”
“When I was 79, I temporarily stopped teaching and singing to cope with more health issues and to work with various kinds of physical and alternative therapies.
During my recovery, I sang in rehab units when I could muster the energy: opera arias, sacred songs, and Christmas carols poured from me as I reclined in my bed. I
made up words when I couldn’t remember them and was surprised at how much joy it brought the other patients and nursing aides. I was just doing it to boost my
spirit and ended up boosting others.”
Francesca believes that around age 80 her voice had declined to a degree that she needed to stop performing. She found that adjusting expectations for her
singing voice, and doing the administration and conducting of her choir, brought a great deal of meaning to her life as well as to others.
Her perspective now is, “My voice feels weak and foggy, although within a certain range, you can still hear me singing a descant over my choir of 30 people.
There is a line in the movie Chariots of Fire where the main character, an Olympic gold medal winning track star, says, ‘I believe God made me for a purpose, but he
also made me fast. And when I run, I feel His pleasure.’ That’s what singing has been for me. God made me for a purpose, but he also made me a singer. Even now,
when I sing, I feel his pleasure.”
Many professional singers stop performing completely when they can no longer make music the way they used to, or the way the industry values and demands.
For those whose voices continue doing well, keeping the voice in top shape can take a great deal of time and mental energy. Still other singers are ready to retire
from this demanding regimen but enjoy singing casually in their community.
Having a deep, lifelong, and spiritual passion for singing was mentioned by most of the women we talked to who were in their 70s and 80s. Judith, age 81, started
her story in a way that brought us back to the time before computers and television. “After dinner, my dad would sit down at the piano and we would all stand around
him and sing. We’d sing some church hymns like ‘Bringing in the Sheaves’ but mostly community songs from the Fred Waring Song Books .” Singing is tightly woven
into her identity. Judith has been in some type of choir starting from the age of nine.
She currently performs with an auditioned community choir. She used to be a soprano but ended up in the alto section. “For sure my upper notes are not as
pleasant to hear as they used to be. There are several of us who, in our 50s, decided to be altos. I don’t really have very low notes. Switching to alto was
disappointing because supposedly the sopranos are more important. However, harmonizing is fun for me.”
Judith continued, “I cannot imagine my life without music. It’s part of my sanity. The time may come when I decide I don’t have the energy, or I don’t like my
own voice. Then I will drop out of my auditioned choir. If it comes to that, I hope the church choir will still put up with me, because when you are singing in a group,
it is larger than the sum of the parts.”
She ended her interview by singing part of the song, “Ac-Cent-Tchu-Ate the Positive” popular during World War II. Judith would have been in grade school around
the time the song came out.
In the amateur choral world, it’s a common misconception that being switched from singing first soprano to a different part is a demotion. This comes from the
idea that being able to sustain a high vocal line means one is a better or more important singer. However, second sopranos often can sing just as high as first
sopranos but may have a voice quality or size that provides stability to the ensemble by singing an inner part. Soprano leads in opera or musical theater sometimes
sing inner parts in ensembles to balance other voices and parts. It is all about what serves the music, not a statement that higher is better.
S UPPORTING S INGERS WITH P ERSONAL O BSTACLES
Like Judith, Evelyn at age 88, started out the interview by telling us how strongly she feels about music and how her childhood, which was filled with music, shaped
her life. “Music has been the most important thing in my life. My parents were professional musicians. Dad was a university band director and Mom was a concert
pianist. I was a flute player by training, but I also sang in a select choir in college. As a kid, I loved listening to opera.”
Evelyn stopped singing after college, but in her late 30s she missed it so much that she started singing in her church choir and has continued for over 50 years.
Formally a soprano, her voice has gotten lower, so she sings alto.
However, getting to her choir rehearsal is a challenge because she doesn’t drive, and her husband doesn’t either due to vision loss. Fortunately, other members of
the choir have arranged to give them rides.
A few years ago, Evelyn had a small stroke that caused a difficult change: she can no longer read words. She said, “Words look like a foreign language now, but I
can still read musical notes for some reason! In choir, if I don’t already know the words or can’t pick them up from the other singers, I don’t sing the words, just the
notes. But whatever has happened to my brain from the stroke, I’m singing something all the time inside my head. It’s just amazing! I don’t choose what it is, but
there is always something that I’m singing in my brain. It’s not out loud. I can hear it, but it doesn’t affect my hearing or other things. Today it’s For All the Saints .
Over and over and over, very softly, but it’s there.” She was smiling as she told us this.
In brain function, reading music differs from reading text in a number of important ways, so her stroke did not affect her ability to read music. Since music is so
important to her, her friends who give her a ride to choir are giving her a bigger gift than they likely realize.
Any cognitive impairment can bring life changes and a great deal of confusion and sadness. However, oftentimes the musical part of the brain continues to
function relatively well, even into the later stages of conditions like Alzheimer’s. Though she didn't have Alzheimer's, co-author Joanne Bozeman's mother, Beth,
developed mild cognitive difficulties and sudden hearing loss after a brain injury. Thankfully, her beautiful and youthful-sounding voice remained intact. Beth sang in
her church choir until not long before she died at 89. Kind friends and neighbors helped her to continue to participate. The neighbors gave her rides to choir practices
and church services, and whoever sat next to her in choir made sure that Beth had the right sheet music and helped her find her place if she got off track. At home,
Beth enjoyed singing and vocalizing every day, usually while she rode her exercise bike.
 Singing can be a lifeline for the elderly. It is essential that they have opportunities to sing with other people. But it isn’t just older people who need singing. Any
of us who are tempted to give up on singing because our own voices don’t meet our personal expectations of our “best” need to reconsider. For too many of us,
“singing” means performing. But that overlooks the countless benefits we receive from casual and community singing. Singing helps us, body, mind, and soul, to deal
with the challenges we will all face.
I have my tea and honey, I do my vocal exercises and I’m still boxing. I have pink boxing gloves.
Mavis Staples, at 80, Professional American Blues Singer
Chapter 10

WHERE TO GO FROM HERE

We tend to think that any change in the status quo is a bad thing, but in art, change is a good thing. If we can use menopause as an infusion of new ideas or a new
energy into an artistic career, it should be viewed as a new chapter, and not as a death knell. [118]
William Riley, American Voice Teacher and Singer
After all that we have learned, it’s time to discuss how to move forward. In order to do that we need to consider overlapping issues of menopause, genre
requirements, illnesses, physical condition, aging, and more. It is clear that finding the right combination of care from a variety of disciplines and using a team
approach for healthcare can preserve a voice into later years. There is no one-size-fits-all solution. Each woman’s situation is unique.
O VERLAPPING I SSUES C AUSE C OMPLEX R ESULTS
We are aware of at least six points that can impact a woman's experience with her voice during the menopausal transition. They can overlap.

Perimenopause: (before menopause) this is the two to ten-year period of time when female reproductive
hormones begin to decline, often erratically. Most people know little about perimenopause and even less about its
impact on the voice. Nearly 50% of women in Elliott’s survey reported voice changes within a year following the last
period. [119] These 12 months are currently considered part of perimenopause.

Postmenopause: (after menopause) this follows the cessation of menstrual periods after one year, and is
associated with a permanent drop-off of estrogen and progesterone to levels much lower than in the reproductive
years.
 Psychosocial Conditions: these include emotional health and wellbeing, as well as socio-economic status, ethnicity,
culture, nutrition, lifestyle, and trauma - any of which can impact the experience of the menopausal transition and
aging.

Physical Health and Medications: underlying physical conditions can impact the voice independent of potential
hormonal influences. They may also impact the menopausal transition. Medications can affect the voice.

Underlying Voice Health Problems and Access to Appropriate Voice Care: a lack of diagnosis and appropriate
care for voice issues can lead to a delay in recovery or to a disabled voice.

Aging: this has many varied effects on the body and voice that are related to changes in muscles, bones, cartilages,
nerves, and other systems. Women’s hormonal and age-related changes and adaptations unfold over years. In the
study, The Impact of Menopause and Hormone Therapy on Voice and Nasal Resonance, the authors state, “One of
the major difficulties in this research field, is the distinction between the effects of the aging process and those of
the menopause.” [120]
It’s common for multiple issues to come together to create challenges to singing. Melissa, age 45, is one of the people this happened to. Her physical health and
perimenopause both contributed to her difficulties. Melissa is a voice teacher and professional singer. She is currently in perimenopause; and because of the hormone
changes, she suffers from emotional swings, night sweats, heavy periods, and flooding.
Melissa had other health challenges that impacted her singing as well. She was diagnosed with laryngeal reflux which led to a vocal fold cyst. She recovered,
surprisingly, after having her gallbladder removed for an unrelated reason. She also had the help of a speech therapist and changed her diet. The combination of
improved diet, speech therapy, and resolution of the reflux cleared up the inflammation to her vocal folds and throat.
However, not long after that, her husband had a stroke. During his recovery Melissa learned more about healthy eating and realized that she had to address her
habit of using food as a stress-reliever: she had to stop emotionally driven eating. With the help of a nutrition program, she now eats better and has lost a great deal
of weight. She explained, “For me, eating well and not compulsively is really important. The improved diet is helping my gut. It’s symbiotic. If your gut is good, then
your brain and emotions are better.”
Her voice feels better now, too. Melissa added, “I also worked with a teacher who urged me to play around with my very lowest range by using vocal fry and
other unusual but healthy sounds.” Vocal fry is used in voice therapy as a rehabilitative tool. “They have all helped my singing. Perhaps my voice doesn’t do what it
used to, but there may be some cool new sounds I can make now!”
Adjustments to voice changes as we move through life may include an evolution in our emotional relationship with singing. Melissa told us, “You know, when I
was young, I sang for joy, simple joy. I can’t quite say that now. Maybe it’s because I’ve had a lot of training, and because I’ve been through some rough times.
Singing from a place of joy has kind of stopped. Still, singing fills something in me. And helping others feel comfortable with their singing is very satisfying.”
T HE R OLE OF R EPRODUCTIVE H ORMONES IN THE B ODY
As we’ve discussed throughout the book, the endocrine system has a dramatic impact on our bodies and therefore our voices. Cells throughout the body have estrogen
and progesterone receptors, including those found in the vocal folds, the brain, the immune and cardiovascular systems, tiny structures in the ear, muscles, bones,
ligaments, tendons, and in many other areas as well. It is amazing to us to witness the individual variations in how women’s bodies respond to fluctuations of the
menopausal transition and the rebalancing of hormones with aging.
One woman who struggled with her hormone changes is Elena, 50, a choral conductor and singer in Romania. Her perimenopause lasted about ten years, starting
in her late 30s and ending in her late 40s. Elena said, “As a choir leader I teach different styles of music for children, youth, men, and SATB choir. I also teach in a
psychiatric clinic. In the clinic we sing very easy, healing music.”
In her late 30s, Elena didn’t menstruate for several months. After repeated pregnancy tests showed she wasn’t pregnant, she learned from her mother that
irregular or delayed menses was a symptom of perimenopause and then things clicked into place for her. She realized she very possibly couldn’t get pregnant because
she was in perimenopause. She told us, “I just didn’t expect it would start so early.” She didn’t experience any troubling vocal symptoms, but quoted a saying from
her culture, Himmelhoch jauchzend zu Tode betrübt (On top of the world, in the depths of despair). The mood swings of perimenopause reminded her of going through
puberty.
Elena is now about two years into menopause. Her life is rich with music, but she finds it challenging to accept her physical self-image. “I saw myself as fat,
ugly, unattractive. These changes were not easy for me. So, I began to seek my inner balance. I started reading psychological books, attended counseling courses, and
practiced meditation and spiritual disciplines.”
Her vocal transition into menopause has gone more smoothly than other parts of her physical transition. She noted, “I remember when my voice improved one or
two years ago. I noticed it when I introduced a piece for my choir. I was fascinated. My voice is growing along with my growing self-confidence. And also, singing is
so much easier when the soul is singing.” Now she feels it is her duty to raise her voice, both literally and metaphorically. “Singing is a powerful tool for being the
change you wish to see in the world.”
Like Elena, Alejandra, a 60-year-old professional, classical singer from Mexico, said that as her hormones settled down, her voice improved. “It has gotten better
with age; it has more body. My pitch accuracy became better. There is a more interesting quality of voice. I express more emotion in my singing.”
When she was younger, Alejandra hit a vocal rough patch. She said, “I made adjustments to repertoire and extreme high notes because of a surgery on my vocal
cords. I decided I didn't want to be at risk of another injury again. So, I’m very careful of what I sing. If a song presents extreme performance, I train myself slowly
to achieve the stamina for it. I now always take enough time to prepare everything.”
Alejandra also exercises more now than when she was younger. She told us, “I have turned to dance for healing. Menopause is an opportunity to start over, a
rebirth of energy, a second wind to life. What I learned growing up was that menopause was a time to slow down because you were getting old. But what I see now
is that it is more a time to let go of many things in order to create a better life. Part of that is the understanding that some things will come to an end. But that’s
quite a different view than the one that says you slow down!”
Elena and Alejandra are good examples of women who are experiencing a full rich voice on the other side of menopause. Something about their hormonal
transitions, and perhaps the ways they dealt with change, have worked in their favor. But as we know from many of the other women, this is not the case for
everyone. If we better understood the way hormones interact with every part of our bodies and minds, perhaps we would be able to optimize the outcome for more
women.
K NOWING W HEN TO W ORK WITH M EDICAL P ROFESSIONALS
It can be hard to tell if voice problems come from changing hormones or if the problems are from other medical issues that should be addressed by different
specialists. Since we have hormone receptors throughout our vocal fold tissues, hormone fluctuations can have a dramatic influence on the voice; but there can be
other factors, including reflux, thyroid conditions, and upper respiratory tract infections.
Like many of the women we talked with, Amanda, age 58, had problems with both hormone changes and medical issues. Amanda sang professionally in many
styles and was a member of a military chorus. “After I had our child at age 35, I lost my highest notes and my total overall range lowered. However, my confidence
increased, and I was hungrier than ever to perform. I went into menopause in my mid-40s, and during that time I had lots of emotional ups and downs. Now, 12 years
later, I still get night sweats!”
Amanda said that during the first few years of menopause, “Singing was unpredictable and challenging in ways I had never experienced. I had come to terms with
losing the very top notes, C6 and higher, but things that used to be easy were now difficult, like high, long, sustained phrases and loss of top staccato notes. It was
confusing that one song would be hard, but then I could sing a similar song without trouble. I ended up performing less because I wasn’t sure how my voice would
work under pressure. It's a slippery slope: muscles need to be used, and if you don't exercise them, you lose strength. But performing was very strange during that
period.”
We heard from many women that after menopause their voices stabilized. Fortunately, that was the case for Amanda. Her high notes eventually improved, and
she had a long stretch of comfortable singing. Thanks to some technique adjustments, the fullness of her voice also returned.
Then she caught a bad cold with a lingering cough. “After that I couldn't get much sound. Practicing, which usually makes me stronger, made my voice tire
quickly.” It was clear to Amanda her voice was not bouncing back from the cold and coughing. “I had one exam with a local ENT who told me, ‘Your vocal folds are
swollen.’ Obviously! I took three rounds of steroids and cough medicine. When the semester was over, I rested my voice for several weeks. And I drank water,
water, and more water.”
But her voice didn't improve with rest, so she went to a laryngologist at a specialized voice clinic. The exam with the laryngologist showed that her vocal folds
were not damaged, though their movement was restricted. This subtle symptom that the vocal folds weren't moving quite correctly is the kind of thing that can
easily be missed when examined by someone other than an experienced vocal function and health care expert. The clinic provided her with a speech therapist who
was also a singing voice specialist. They spent an hour doing voice therapy exercises targeted to her specific needs and by the end of the appointment Amanda was
able to regain some ease in her singing. “It was slow going,” Amanda said, “but I worked on those exercises over the rest of the summer. Learning the techniques
has changed my singing. It is better than it has been in a long, long time. Singing is easy again. Oh, what a relief.”
Being able to sing is essential for Amanda, as it is for so many of the women we interviewed. At a time when her ability to sing was at risk, she didn’t accept
the word of the first ENT she consulted. Instead, she took the extra step to see the best medical professionals she could. “Singing is physically satisfying, a part of
my life that is primal and organic. It isn’t your fault if you are a skilled singer and you run into trouble. Find someone to help.”
Access to specialized voice care can be imperative for everyone who depends on her voice to make a living: teachers, singers, actors, voice-over artists,
salespeople, and many others. For those who live in large cities and near major universities, help is likely nearby. People who live in smaller cities or rural areas may
have to travel to get the best care. In an ideal world, people who need voice care wouldn’t have to wait to see a specialist or go without treatment because of cost
or distance. However, in many places and with some insurance plans, doctors with general practices are the only medical option available. Most ENTs and general
practice doctors, who see patients with everything from hearing loss to sinus infections, simply aren’t prepared to provide the level of specialized care required by
professional voice users.
In addition, it’s important to realize that medical professionals, whether they are dealing with professional voice users or the general population, might be
unaware of the correlation between voice function and menopause.
F INDING THE R IGHT C OMBINATION OF C ARE
Sarah, age 64, had medical conditions that were not handled well in the medical system. Fortunately for her, convenient access to excellent voice care saw her
through. Sarah is a singing teacher and was a professional classical soloist, actress, and choral singer. Her perimenopause started in her mid-40s. “Low energy wiped
me out. I also began experiencing word loss and issues with memory. My temper could rise and accelerate out of nowhere.”
Sarah also had a hypothyroid condition and experienced prolonged, deep sadness. She was prescribed antidepressants and thyroid medicines by a doctor and an
endocrinologist. The dosage of the thyroid medication was disastrous for her: she experienced hyperthyroidism as a result. After Sarah was taken off both
medications, she felt she had aged and changed considerably. The perimenopausal symptoms, thyroid issues, and several physical and emotional traumas caused her
to stop singing for a long time.
“Two friends told me they thought my depression had been misdiagnosed. They wondered if it was from perimenopause. One gave me a book that discussed
perimenopause, and I actually started working with the doctor who wrote it. I began to feel better with her help and advice. I often run into women who are not
familiar with the symptoms and solutions for midlife hormonal issues. I consider it to still be a problem in our society that it isn’t discussed openly.”
Along with the emotional upheaval, Sarah experienced vocal turmoil starting in her mid-40s. Her light voice began to sound thinner, and it was a struggle to sing
above the staff. “I had a lesson with a neighbor who is a professional opera singer and to his ear there was atrophy, not just singing too little. There was some
improvement once I started singing on a regular basis again.”
By her mid-50s, she encountered new troublesome voice symptoms, so she finally went to an excellent voice care facility at a nearby university. They diagnosed
severe reflux due to a hiatal hernia, and the suspected vocal fold atrophy was confirmed. Sarah worked with a speech therapist who was also a singing voice
specialist. The therapist gave her exercises to strengthen the weakened muscles and her singing got better.
But there were more challenges to come. After about a year, at age 57, Sarah entered menopause, and once again her voice suffered. She explained, “My voice
completely stopped working on notes above the staff. I couldn't make any sound. I wasn’t actively performing at the time, but I felt this jeopardized my ability to
teach singing. I returned to the voice therapist and we focused on strengthening exercises. They really helped and I still use them. I also started taking a bit of
estrogen. I think it's the combination of the right vocal exercises plus estrogen that helps. Estrogen wasn’t prescribed to make my voice better, but I learned through
my own experience how much it helped my voice. In addition to the estrogen, I still would have needed strengthening at the vocal fold level. My singing loss was
taken seriously because I had access to excellent voice care at a reputable voice clinic. Due to this late life training, and in spite of some stamina issues, I think my
singing is in some ways freer and healthier than when I was younger.”
A DVANCING R ESEARCH
Hormonal changes on female voice of all ages first appeared as a topic in a few articles in Europe in the 1940s. Other professional voice journals picked up the topic
in the 1970s. In the 1980s, voice researchers, particularly Dr. Jean Abitbol and Dr. Beatrice Abitbol, did studies that showed conclusively that reproductive hormones
have direct effects on the female larynx. [121] Other researchers and voice experts added to general knowledge as well. However, by 2011, there were only five
published research studies on singing voice and menopause, which included a total of only 248 female singers! [122] While experienced laryngologists and other voice
professionals have contributed valuable research and opinions on this topic, and have presented these findings in academic and professional journals and conferences,
this information has not been written for the population at large.
 Beginning in the late 1990s, female academics and other researchers began asking female singers directly about their personal experiences. [123] These
researchers were the first to seek out and record first-hand reports of how female voices actually feel and behave during the menopausal transition. Some of the
researchers considered how singers’ emotional states are affected by the changes. This research has opened the door for consideration of the direct and indirect
vocal consequences of many non-voice menopausal symptoms. Those symptoms might also include sleep and cognitive issues.
A DVOCATING F OR O URSELVES
All women who experience difficulty with singing should find a sympathetic and knowledgeable voice expert to talk to. Ask singing specialists and doctors questions
such as: Can you reword that? What are you seeing and hearing that causes you to draw that conclusion? Are there other possible causes of this issue? What are all
the treatment options? We must build our knowledge and become smart healthcare consumers by studying multiple sources of information. In spite of efforts to
communicate clearly, if the healthcare provider does not respond to your concerns, consider seeking someone else to get a second opinion.
Advocating for ourselves and making known the need for credible information about the unique issues female singers face is essential to encouraging more
research. Thankfully, a few professional female singers have publicly discussed menopause and singing, and some professional singers have also spoken publicly about
the aging voice. Yet, Valerie, an elite opera singer, did not know about these changes at a critical point in her career.
Valerie performed in major opera houses in Europe for many years. Now at age 67, she remembered, “When I was in my 40s, in the midst of my career, things
could have been better with my voice. There were some subtle changes. We think we know our voices very well, but sometimes we get into problems without even
knowing we are sliding into them. That’s what happened to me. If I had to do it over again, I would have found a teacher, especially to help through menopause.”
“Back then, people in the opera community didn’t talk openly about menopause. On the other hand, I remember when one of my favorite mezzos performed. The
tone was stunningly beautiful, but she was a quarter step flat. Somebody said that the mezzo was going through menopause. That should have been like a huge red
light going off in my head, but I didn’t think it applied to me yet.”
In her late 40s, feeling the need to have a more stable life and community, Valerie moved home to the United States. She began teaching at a university and
continued performing, though no longer in opera. As she approached menopause, she found herself feeling irritable and aggressive. She had night sweats and hot
flashes. She noticed more obvious voice changes including struggles with intonation. “There was a time when I was really having trouble holding pitch well - that
sinking, that going flat. During perimenopause, I remember practicing and thinking, ‘Oh, this is great’. And then I’d check my pitch at the piano and, oh, my gosh, I’d
be a half step flat! That was disturbing. There was a period of time when I did not like the sound of my voice. I would not practice because I didn’t like the sound of
it, and I didn’t like the way it felt. I am so glad that once I entered menopause at 57, things started clearing up a bit. My pitch got much better. But it’s still
discouraging because I can’t do the things now that I could before. You have to do things a different way to get the same effect…or not do it at all. Yes, it is a
completely different instrument.”
Valerie asked us to pass on a message to singers. “Even if you don’t have to worry about it now, be aware that the voice does change. Pay attention. Find a
teacher that you really like, that you really trust, and who knows about female voices that are aging. And do that whether or not you are noticing anything. Have
someone in your life that can help you through those times. I wish I had done that. I think I could have helped myself more. At the same time, I am not sorry about
how my life turned out. I am happy and satisfied to have had my career. But my late 40s would have been less stressful if I’d had help with my singing. My decision
to not perform so much would have truly been my decision, and not my body’s decision. I would have been fully informed.”
W HAT TO L OOK FOR IN A V OICE T EACHER AND C HOIR D IRECTOR
Aside from helping a woman sort out vocal issues, the therapeutic aspects of voice lessons and the community of a choir can make a world of difference for a
singer. Look for singing teachers and choral directors who welcome midlife and older female singers with open arms. Keep in mind, licensing and certification are not
required to be a voice teacher or choir director. There are no guarantees of quality, regardless of experience and training. Ideally, choir directors or singing teachers
should be able to help a singer explore vocal issues and refer to other appropriate voice specialists when needed.
Another valuable resource for women who are sorting out voice issues are singing voice qualified speech-language pathologists. These specialists can help a
woman re-balance her voice, deal with technical frustrations that may have developed, and establish appropriate singing habits. There is a misconception that these
clinicians only work with injured voices, when in actuality, they are well-equipped to help singers through a vocal rough patch with targeted voice therapy and singing
technique. Many of these SLPs are affiliated with voice clinics or have private practices and voice studios.
Because of a variety of factors, many women have few options for who’s available to help them. But if there are multiple possibilities, seek out a person with
patience, compassion, healthy personal boundaries, flexibility, humor, and the ability to inspire. These attributes are not always addressed in the training of voice
teachers and choral directors. Due to coursework time constraints, and a traditional focus on training young professionals, it is challenging to include all the skills and
knowledge to teach singers throughout the lifespan. Nonetheless, in the 21st century, voice teachers have more opportunities than ever to broaden their ability to work
with singers from childhood to older age.
C LOSING T HOUGHTS
We have heard the voices of real women talking about the experiences they’ve had singing through midlife and beyond. This is the first time that any published source
has shared so many women’s individual experiences in a book. But these are the stories of only 56 women and represent only a tiny fraction of the population of
women who sing during midlife, menopause, and beyond. The good news is that because of rapid advances in communication and health sciences, we are now able to
help women overcome these vocal issues and offer emotional support throughout this potentially troubling time.
At certain phases of the hormonal journey, many women need empathy and skilled assistance. Support comes through respecting what singers are experiencing,
assisting with solutions as needed, and encouraging them to continue singing. Knowing they are not alone can be an enormous relief. Voice is intimately linked with
identity. When a woman’s voice is not functioning as expected, it can throw her life off balance. We encourage women to listen to their bodies and hear what their
bodies are telling them through their symptoms.
Fortunately, statistics so far indicate that fewer women experience serious voice problems in the menopausal transition than women who don’t. It’s not our aim
to create only negative expectations. However, saying nothing or highlighting only positive experiences is not helpful for the women who do have trouble. For those
with no major vocal issues during these years, learning about the hormonal shifts of perimenopause and postmenopause versus the effects of aging can also be
beneficial and empowering.
There is still much to discover and understand about the female voice and, particularly for singers, how it is impacted throughout the stages of life. To that end,
we must continue to expand our research and knowledge until all women are able to keep singing for as long as they choose.
APPENDICES

Appendix A

Hormone Therapy for Symptoms of Menopause

Note: The authors cannot offer medical advice regarding hormone replacement. They advocate for access to current and balanced medical
information about its risks and benefits for women who are considering its use.
Estrogen and progesterone are two hormones that play key roles in the menopausal transition. As women age reproductively, these hormones decrease, causing many
changes in a woman's body. If the symptoms become problematic, supplementation with estrogen can help to minimize difficult perimenopausal and post-menopausal
physical and cognitive symptoms. If the woman has her uterus, progesterone would likely be prescribed as well. The practice of supplementing the body’s hormone
levels during perimenopause and after menopause, currently called hormone therapy (HT) or menopausal therapy (MT), began in the 1940s.
Nonetheless, a number of women and caregivers have concerns about the use of HT. These worries may be holdovers from reactions to the Women’s Health
Initiative (WHI) study that was halted prematurely in 2002 due to small increases in several health conditions in a group of older women who were given HT (Prempro
®
). The discontinuation of the study was featured heavily in news reports, though the press “tended to overstate the cautionary findings and overemphasiz[ed] the
abrupt halt.” [124] Shortly thereafter, the number of women using HT plummeted, with prescriptions falling to 70% of previous levels. [125] It is likely that some of the
women who went off of HT included medically low-risk singers who had been using it to help sustain their voices during perimenopause and after menopause. Use of
HT by female singers had previously been advised by voice care professionals, due to clinical opinions and studies that showed it counteracted effects on the voice
from estrogen loss. [126]
However, since 2002, there have been re-evaluations and criticisms of aspects of the halted WHI study as well as nearly two decades of continuing research on
the health effects of HT in women. [127] Due to these ongoing investigations, medical opinions have evolved regarding appropriately timed use of HT by low-risk
women. Medical organizations specializing in menopause now advocate for an individualized approach, based on the health history, specific needs, priorities, and age of
each woman. [128] In spite of current, more nuanced protocols for use, and understanding of certain positive health effects of HT, news reports of these changes of
opinions and practice have never reached the saturation levels of those of the WHI study. Singers who are contemplating HT may need to discuss with their doctors
how voice changes can be a symptom of the menopausal transition [129] , and that indications are that it can have positive effects on voice. [130] , [131] Outside of voice
care professionals, it is unlikely that gynecologists and other medical caregivers were exposed to this information in their medical training.
Further research and refinement of recommendations will unfold in the future. Hormone therapy has effects on other important aspects of health besides voice,
so it is wise to make an informed consideration with the caregiver. To help start a discussion, up-to-date information and position papers for medical consumers and
healthcare providers are provided on the websites of menopause-oriented national and international medical consortiums, listed below.
North American Menopause Society: menopause.org
International Menopause Society: imsociety.org
European Menopause and Andropause Society: emas-online.org
British Menopause Society: thebms.org.uk
Appendix B

When to See a Voice Doctor and Where to Find Voice Caregivers

Note: Due to the world health crisis of COVID-19, typical ear, nose, and throat care may not be available for a time except in medical emergencies.
However, we have been advised that voice care and consultations may be available via telemedicine or telepractice and through other online voice
care providers. Contact your clinic for detailed information. We will post updates and links to more resources on the Singing Through Change website.
Most adults have an idea of when they don’t feel well and need to see a primary care doctor, go to a clinic, or to the emergency room. We generally know the typical
symptoms of something that needs immediate attention, or when our condition warrants a “wait and see” approach.
Decisions about voice care, however, may not be so obvious to us. But, if we learn the basic symptoms, we’ll have a better idea about whether a voice condition
needs immediate care or whether we can wait and see if the voice gets better over time. Here are some things to look for.

Sudden Changes: If there’s a big voice change that comes on quickly, avoid using your voice at all and see a voice doctor right away. The clinic or office nurse
should be able to schedule an emergency appointment. Voice changes to consider include:
Sudden hoarseness
Sudden roughness
Sudden vocal instability

Lingering Problems: [132] When voice problems last for two weeks or more, make an appointment immediately if:
After an illness, a lingering cough and/or hoarseness doesn’t improve.
You experience reduced vocal range or reduced singing range.
Without underlying illness, you experience any of these for two or more weeks: voice fatigue, hoarseness, lowered pitch, strain, unusual weakness or
breathiness.

Chronic Problems: [133] , [134] If these voice problems occur often or don’t go away, they should be checked out by a voice care professional:
Very frequent feeling of a lump in the throat
Near-daily lower than normal voice, especially in the morning
Frequent need to clear the throat
Frequent sinus drainage
Frequent coughing
New voice instability
New problems with register transitions
Regular difficulty with high, soft range
Frequent aching of the throat
Constant increased effort or strain with voice use

V OICE C ARE D OCTORS

A doctor that cares for the voice is called an otolaryngologist , or ENT (ear, nose and throat doctor). All ENTs have many years of medical training, including five years
of residency in otolaryngology. Some focus their specialty by doing one to two additional years of fellowship training in one of eight separate subspecialties. In the
U.S., ENTs who pursue specialty training and pass exams in voice and throat care are called board-certified laryngologists . In other parts of the world, voice care
doctors may be called phoniatrists, phonosurgeons, voice surgeons, or laryngologists . While some ENTs focus on one or two subspecialties, others choose to work in a
broader range of practice. [135]
When voice care is needed, the ideal doctor to see is a board-certified laryngologist. [136] In the U.S., fellowship training has only been available since the early
1990s. Therefore, a number of older otolaryngologists with expertise may be excellent voice doctors, even without fellowship certification. [137]
The ideal setting is a dedicated voice clinic, which typically includes at least one laryngologist, a speech-language pathologist who works with singing voice, and
collaboration with voice teachers who have special skills to help singers further recover after being treated in a clinic.
Many singers do not have convenient access to a top-level voice care clinic, most of which are in large metropolitan areas or attached to university medical
schools. For those who are able, it is worth the time and effort to travel to one of those clinics. However, some singers do not have health insurance or funds to
cover these kinds of exams and services. In smaller communities, there may or may not be ENTs with voice experience and the specialized examination instruments
needed to closely examine the vocal folds. If singers need to see a local ENT, they should ask if the doctor can do an examination withvideolaryngoscopy,a procedure
that offers a magnified view of the vocal folds. [138] Stroboscopy is another essential tool which allows the doctor to see the vocal folds movement with great detail
under a strobe light.
O THER V OICE C AREGIVERS
Speech-language pathologists (SLPs), known as speech therapists in some countries, have completed master’s or PhD degrees in the field. SLPs may work in a number
of specialties, including speech disorders in children, language recovery after brain injury, treatment of swallowing disorders, and more. Some SLPs choose to
concentrate on singing voice rehabilitation [139] and may be called singing voice specialists . They receive further training and clinical experience, and may have
experience as singers. These practitioners are often affiliated with a voice care clinic, though some practice independently.
Singers who are not having serious voice problems, but who need help through a time of transition, such as perimenopause, menopause, or getting older, can
benefit from working with a singing voice specialist SLP or therapist and might not need a referral from a doctor.
Other voice caregivers are singing teachers who have a special interest and training in helping singers resume healthy singing habits after treatment for a voice
injury or surgical procedure. Several programs are available that offer specialized training to singing teachers. [140] Many of these teachers are affiliated with voice
care clinics and receive referrals from them. Other singing teachers with voice rehabilitation experience practice independently, having pursued continuing education in
the field. They often receive referrals from voice doctors and clinics and are sometimes known as vocologists. These specialized teachers are also equipped to help a
singer who is encountering transitional voice changes.

R ELATED O RGANIZATIONS & C LINIC/ P RACTITIONER L OCATORS

American Laryngology Association:
alahns.org

Johns Hopkins Voice Center National Referral Database:

gbmc.org/voice

The Voice Doctor: International Physician List:

voicedoctor.net/physicians
Appendix C

Vocal Fold Paresis

Vocal fold paresis (VFP) [141] is a condition when the nerves that control the muscles of the larynx (voice box) become impaired. These nerves are important for
speaking, breathing, and swallowing. Sometimes people use the words “paresis” and “paralysis” interchangeably but the difference is in the severity of muscle
impairment. Paresis runs along a spectrum of mild to severe, which will influence protocols for treatment, prognosis for healing, and how one’s respiratory and
swallowing functions are affected. Paralysis implies complete denervation which means no vocal fold movement. Unilateral paresis (one vocal fold) is much more
common than bilateral paresis (both vocal folds). People of any age can experience VFP.

There are many reasons why paresis occurs, and may include:
A viral infection
Head or neck injuries
Surgery on the thyroid gland, neck, or within the upper chest.(One of the main nerves for the larynx runs past the neck, dips down into the chest area, and
turns back towards the neck.)
Intubation from surgery, which is done with general anesthesia to support the airway and provide oxygen. Usually a flexible tube is inserted into the mouth,
down the throat past the vocal folds and into the trachea (the “windpipe”). Then a small balloon is inflated below the vocal folds to make sure liquid
doesn’t get in the trachea. Before surgery, it’s very important to speak with your anesthesiologist and surgeon to let them know you are a singer and
request that they use the smallest tube size that will protect the airway, but to minimize the chance of injury to the vocal folds during the procedure.
Singers should also discuss balloon pressures with the anesthesiologist as “pressure on the mucosal lining of the trachea has been associated with
temporary vocal fold weakness because of pressure on the recurrent laryngeal nerve.” [142]
Sometimes the cause is unknown.

VFP is not the result of poor technique, and in fact, the vocal folds themselves are usually not impaired. There are fine singers with mild vocal fold paresis who
continue to sing well and may not even be aware that one vocal fold is slightly impaired. If paresis is diagnosed, then voice therapy can be done with a speech-
language pathologist who is also a singing voice specialist, and/or withan experienced voice teacher who has the training necessary to work with injured voices. Voice-
injured singers need specific training and skills that most singing teachers and performers do not have.
Therapy will help establish as much voice efficiency as is possible, and help the client resolve any muscular tensions in speech or singing that result from trying
to make sound with a weak vocal fold. In the case of paralysis, doctors often inject a filler into the affected vocal fold to bring it closer to midline for better voicing.
Therapy following the procedure can help improve voicing as well. If the nerve does not appear to be recovering over time, then a tiny structural implant may be
placed alongside the affected vocal fold to move it close to midline. Discuss the pros and cons of these procedures with your caregiver. If voice therapy is not
offered as part of the treatment plan, singers will need to seek out the help they need to learn the best ways to use their voices.
ACKNOWLEDGMENTS
Singing Through Change could not have been written without the generosity and assistance of many others. At the top of the list are the women whose stories we
share. They made themselves vulnerable and shared deeply personal matters and concerns. We have the greatest respect for them and sincerely appreciate their
contributions. As we learn from other women's experiences, our daughters and granddaughters will have a smoother time singing through midlife and aging.
We are grateful for the brave women who covered this subject before us, Barbara Fox DeMaio, DMA, Rebecca Mosely-Morgan, Kathy Kessler Price, PhD, Patricia
Vigil, DMA, Vindya Khare, DMA, Anne Richie, DMA, Catherine Froneberger Sirarris, DMA, Martha Elliott, and perhaps others we are not aware of. Their contributions are
a key part of our work. We hope our work will be part of that foundation for generations to come.
Our thanks go out to Dr. Jean Abitbol and Dr. Beatrice Abitbol, important researchers in the effects of female hormones on singing, as well as the many other
researchers who have explored hormones and voice and aging voice.
We thank SLPs Lori Sonnenberg, Jan Potter Reed, Kristine Pietch, Joanne Cazden, Marci Rosenberg, and Kerrie Obert for conversations and generous insights on
singing voice rehabilitation.
We thank Karen Brunssen, Peggy Baroody, Darryl Yeagley, John Nix, Kari Ragan, DMA, Chris McCafferty, Sandy Hirsch, Mary Sandage, PhD, Petra Borzynski, Lisa
Erikson, Aaron Johnson, PhD, Jenevora Williams, PhD, Joanna Cazden, Deidre Michael, PhD, Lavanya Murani, PhD, Kate DeVore, Stephen Austin, PhD, Annie Richie, DMA,
and Kathleen Wilson, EdD, for conversations that led us to important realizations.
We are also grateful to the women and men who’ve contributed their questions, experiences and advice on the Singing Through Change Facebook group and
Instagram.
Our heartfelt thanks go out to the experts who helped us ensure the information in this book is of the highest quality from the most recent medical
understandings. These include Lori L. Sonnenberg, MM, MA, CCC-SLP, Lori Nelson, ARNP Women’s Health Nurse Practitioner, Teri Stock, NCVS Trained Vocologist and
Singing Specialist, Curtis Stock, MD, Otolaryngologist and NCVS Trained Vocologist, Dr. Lynn Gackle, Prof. Kenneth Bozeman, Prof. Robert Edwin, and Prof. Cynthia
Vaughn. Thanks also to our book editor, Faith Steinfort, our editor for bibliography and citations, Krista Stevens, PhD, and our proofreaders, Kathleen Smith, Mindy
Carslon, Jennie Hoffman, PhD, Julie Cross, DMA, and Angelene Frazier.
We also deeply appreciate our husbands, John Neely, Ken Bozeman, and Jeff Costlow, who not only supported us during the herculean task of researching and
writing this book, but tolerated months of messy dining room tables and much more take-out food than usual. Particular thanks to Chris Bozeman for designing the
cover, Jessica Bozeman Hronchek for research advice, and Lindsey Costlow for assisting with formatting and creating the website.
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Wikipedia. “Light Therapy.” Last modified March 6, 2020. https://en.wikipedia.org/wiki/Light_therapy .
Wikipedia. “Old Age.” Last modified March 2, 2020. https://en.wikipedia.org/wiki/Old_age .
Wilson, Sarah. “How Music Works: What Happens to Your Brain When You Sing?” By Matthew Lorenzon. Classic FM. August 13, 2018. https://www.abc.net.au/classic/
features/how-music-works-what-happens-to-your-brain-when-you-sing/10115596 .
Wise, Linda. “Essay Voice and Soul –The Alfred Wolfsohn/Roy Hart Legacy.” Voice andSpeech Review 5, no. 1 (2007): 45-52. https://doi.org/
10.1080/23268263.2007.10769740 .
World Health Organization. “Research on the Menopause in the 1990s.” Geneva, Switzerland, 1994. https://apps.who.int/iris/bitstream/handle/10665/41841/
WHO_TRS_866.pdf%3Bjsessionid=B912FBDE86C40BF7BCCA7E505CCA1DEE?sequence=1 .
Zárate, Sandra, Tinnz Stevnsner, and Ricardo Gredilla. “Role of Estrogen and Other Sex Hormones in Brain Aging. Neuroprotection and DNA Repair.” Frontiers in Aging
Neuroscience 22, no. 9 (December 2017): 430. https://doi.org/10.3389/fnagi.2017.00430 .
ABOUT THE AUTHORS

Nancy Bos

Nancy Bos is a professional singer, voice

teacher, vocologist, voice over artist, author, podcaster, and businesswoman. She believes that, for most people, singing is a basic human need and that everyone
deserves the chance to experience the joy and satisfaction it brings. With this book she hopes to help women maintain their ability to join the world in song.
Following her undergraduate education at Luther College, Decorah, Iowa, Nancy began her career as an independent voice teacher in 1995 under the guidance of Dr.
Candace Magner, University of New Mexico-Los Alamos. In 1997 Nancy and her family moved to the Seattle area, where she ran a thriving singing studio until 2018.
Nancy’s areas of expertise include musical theater, rock, pop, blues and folk. Her work focuses on effective storytelling, vocology, and acoustics. She is an
international clinician in popular contemporary singing styles, musical theater, and acoustics. Since coming to the Seattle area, Nancy has served as adjunct faculty at
Cornish College of the Arts, Seattle Pacific University, and Bellevue College. She considers Robert Edwin her principal mentor.
Nancy’s ceaseless enjoyment and study of a wide variety of genres has enabled her to sing professionally in many styles, including bluegrass, musical theater,
folk, rock, and a cappella pop—she even enjoys covering keyboards or bass in bands. She has worked in the recording industry, film, and theater and is a member of
the Recording Academy. In classical music, Nancy has performed oratorio and worship music in cathedrals worldwide, including a service at Saint Mark’s Basilica in
Venice.
In addition to studies in vocology - the science and practice of voice habilitation - Nancy has studied and taught acoustics as it relates to the human voice,
based on the work of Dr. Scott McCoy and Kenneth Bozeman. Her research includes workplace-related hearing loss risk for voice teachers and the effects of drinking
milk prior to singing. She was central to introducing and developing pedagogy practices for transgender singers through the National Association of Teachers of Singing
(NATS), and has worked with injured singers in cooperation with otolaryngologists and speech-language pathologists at the University of Washington.
As host of the Every Sing podcast, Nancy interviews singers and other music industry professionals to highlight the universal passion for singing. Her other books
include the Amazon bestsellers Singing 101: Vocal Basics and Fundamental Singing Skills for All Styles and Abilities and The Teen Girl's Singing Guide: Tips for Making
Singing the Focus of Your Life. Her Singer’s Practice Plan, Log, and Journal - first published in March 2018 - is used by hundreds of singers worldwide. Nancy recently
formed StudioBos Media to support her books and podcast.
Nancy is the Director of Operations for the Voice and Speech Trainers Association (VASTA). She is also Vice President for Membership for NATS (through June
2020) and served as Northwest Regional Governor and Associate Editor of Inter Nos e-zine for the same organization. She is a member of VASTA, the Pan American
Vocology Association (PAVA) and The Society for Education Music and Psychology Research (Sempre). Nancy is a Distinguished Voice Professional through the New
York Singing Teachers’ Association.
Since moving to Washington’s North Kitsap Peninsula in 2018, Nancy has devoted her time to writing and speaking on the value of singing and voice for all people.
nancybos.me
Joanne Hayes Bozeman

Joanne Bozeman was

fortunate to grow up in a Midwestern home filled with music, dancing, and singing. When her family relocated to Arizona, she began voice training, and she later went
on to complete a degree in voice performance from the University of Arizona. Her teachers include Eugene T. Conley, Bruce Lunkley, Teresa Seidl, and Richard Miller.
Joanne began teaching voice lessons while in college and has continued for well over 40 years, maintaining a private studio to this day. In 1993 she joined the
voice faculty at Lawrence University Conservatory of Music, where she taught until her retirement in 2019.
As a classically trained soprano, Joanne was a frequent performer in a broad ranging repertoire of recital, oratorio, and chamber music, often performing with
her husband, tenor Kenneth Bozeman. She appeared as soloist with the Fox Valley Symphony, the Green Lake Music Festival, the Rockford Bach Chamber Choir, and
the Lawrence University Concert Choir and Symphony Orchestra. She has sung on Wisconsin Public Radio's Sunday Afternoon Live at the Elvehjem, appeared as
resident soprano at “Music in the Mountains”, a music festival in Colorado, and was a member of the Orpheus Vocal Consort, a professional quartet. Joanne also
served many years as a church soloist and soprano section leader.
Aside from teaching studio voice at Lawrence, Joanne also taught supporting courses including lyric dictions, basic voice science and acoustics, classical voice
culture, and singing pedagogy for the elementary music classroom. Many of her students have gone on to select graduate schools, young artist programs and singing
careers; others hold positions as music educators, university-based voice teachers, and some have become speech-language pathologists and singing voice specialists.
In addition to her music career, Joanne spent ten years as an ASPO-certified childbirth and prenatal educator, helping expectant parents understand and prepare
for the physical and emotional changes and demands of pregnancy, childbirth, and early parenthood. Her experience as a health educator laid the foundation for
educating and supporting female singers as they encounter physical and emotional changes of midlife.
Joanne has long been interested in voice health and vocology, particularly the effects of hormones on the female adolescent voice and upon voice changes during
the menopausal transition. During her time as voice trainer for the Lawrence Academy of Music Girl Choir, Joanne worked with a select chorus of young women who
were in the midst of adolescent voice maturation. In the university setting, she taught elementary and choral music educators about adolescent voice change of both
genders.
This background formed the matrix of her interest in the female “second voice change.” However, it was Joanne’s own journey through the menopausal transition
and related voice difficulties that spurred deeper research on the subject, leading her to pen the article, “One Singer’s Experience with Perimenopause,” published in
Classical Singer in 2005.
Joanne is a member of the National Association of Teachers of Singing (NATS), the Pan American Vocology Association (PAVA), and the Voice and Speech
Trainers Association (VASTA). She has presented on the topic of female hormones and voice for the Greater Milwaukee Chapter of the Voice Foundation, the South
Florida Chapter of NATS, the Acoustic Vocal Pedagogy Workshop at the New England Conservatory, International Voice Teachers of Mix (IVTOM), and other
professional organizations.
Joanne and her husband are thankful to be grandparents and enjoy traveling and honing their ballroom dance skills.
Cate Frazier-Neely

Cate Frazier-Neely
grew up in a family of professional musicians with a strong choral, vocal, instrumental, classical, folk and jazz background. In 1980, she began teaching singing by
combining the principles of classical vocal pedagogy with the rhythms and vocal functions of popular music. Then she began incorporating yoga and somatic education
into her work with performers. This was long before these concepts became accepted in academic vocal or choral pedagogy. However, she found like-minded
colleagues and master teachers in many different disciplines, and was able to solidify her awareness that singing is a powerful force for health and wellness, even as
she moved through her own former severe health history.
Guided by her, singers have earned contracts with Broadway musicals, Cirque du Soleil, Disney Tokyo, the Virginia Opera, Washington National Opera, and are jazz
artists appearing in venues throughout the US and Russia. She has also worked with child actors in film and stage, teenagers, voice over artists, adult amateurs, and
the hearing impaired. She served as an adjunct faculty member at American University and Northern Virginia Community College and was a Senior Voice/Choral
Faculty member at Levine Music for 20 years. While there, she founded and sustained a vital community women’s chorus program.
She is a published composer with the former Arsis Press and has arranged numerous folk and religious songs for women’s voices. Her published articles can be
found in the Journal of Singing and digital media. For over 30 years she presented for the National Association of Teachers of Singing, The Voice Foundation and
Leadership Greater Washington.
Currently, Cate is a singing voice rehabilitation specialist working with singers diagnosed with vocal injuries. She works on referral from speech-language
pathologists at Johns Hopkins Otolaryngology in Bethesda, Maryland, and as a team with speech-language pathologists and voice teachers in the U.S. and Australia. She
also is a workshop clinician for the Strathmore Hall for the Performing Arts Artist-in-Residence program.
Cate sang professionally for many years in contemporary classical music, cabaret and opera. She worked with instrumental ensembles (including her ensemble,
the Amoroso Chamber Consort, which opened Piccolo Spoleto’s Contemporary Music Festival,) composers, stage and music directors and grant foundations to premier
over 300 American works in eight languages. Collaborations took place with such luminary composers as the late John Cage, Clare Shore (student of Vincent
Persichetti,) Lori Laitman (hailed by Gramophone Magazine,) Anne LeBaron (reviews in The New Yorker to L.A. Times,) and Ulf Grahn (Nevona Records and Royal
Stockholm Philharmonic) She premiered the role of Elizabeth in Chris Patton’s musical, Reunion, at DC’s Signature Theater, which was accompanied solely by laser
harp.
She earned excellent reviews in print media for opera roles from Mozart to Kapilow, solo appearances with orchestras and in oratorio. She has been the Artist-in-
Residence for the Renwick Gallery of Art of the Smithsonian American Art Museum, the National Museum of Women in the Arts and the Smithsonian Associates’
Program.
Cate holds the MM in Vocal Performance and Pedagogy from The University of Maryland/College Park; the BM in Vocal Performance with a concentration in piano
and organ from The College of Wooster, Ohio; a certificate in Leadership Through Emotional Intelligence from Case Western Reserve’s Departments of Psychology
and Business and is an experienced practitioner of Somatic Voicework™ The LoVetri Method. Her principal mentors were Bob and Angie Frazier, Jack Russell, Elizabeth
Daniels and Jeanie Lovetri.
Explored interests that inform her work include the visual arts, expressive arts’ therapy, tribal belly dance, energy healing, world religions and the sciences.
CateFNStudios.com
Have you enjoyed reading
Singing Through Change?
Please write a review online so more people can hear about the book and learn from it.
✽✽✽

For More On This Topic:

Visit http://www.singingthroughchange.com for additional articles, videos, book club worksheets, and research.

Join the Facebook community at https://www.facebook.com/groups/singingthroughchange/

Bring Nancy, Joanne, or Cate to your event to lead a discussion or give a presentation by contacting them through the Facebook group or emailing info@studiobos.com
✽✽✽

Singing Through Change is available in print, kindle, and audiobook. All formats are available on Amazon.

Please share this book with anyone who can benefit: other singers, choral directors, voice teachers, gynecologists, and laryngologists. As we get the word out, we will
be able to advance this important field of research and help women all over the world.
ENDNOTES

[1]
European Choral Association, “Singing Europe,” 2015, http://www.miz.org/dokumente/2015_singingeurope_report.pdf .

[2]
Chorus America, “The Chorus Impact Study: Singing for a Lifetime,” June 27, 2019, https://www.chorusamerica.org/resource/chorus-impact-study-singing-lifetime .

[3]
American College of Obstetrics and Gynecology, 2011 Women’s Health Stats and Facts , Washington, DC, 2011, https://www.acog.org/-/media/NewsRoom/
MediaKit.pdf .

[4]
Wikipedia, “File: Uspop.svg,” accessed February 11, 2020, https://en.wikipedia.org/wiki/File:Uspop.svg .
[5]
Wikipedia, “Demographics of the United States,” last modified March 3, 2020, https://en.wikipedia.org/wiki/Demographics_of_the_United_States#cite_note-CIA-4 .

[6]
World Health Organization, “Research on the Menopause in the 1990s,” Geneva, Switzerland 1994, https://apps.who.int/iris/bitstream/handle/10665/41841/
WHO_TRS_866.pdf%3Bjsessionid=B912FBDE86C40BF7BCCA7E505CCA1DEE?sequence=1 .

[7]
Laurie Barclay, “Voice Changes Common During Menopause,” Medscape, March 22, 2004, https://www.medscape.com/viewarticle/472174 .

[8]
Tamara Bernstein, “Is the Opera House Hot or is it Just Me? (Effects of Menopause on the Voice),” Classical Singer 18 (March 2005): 26-29.

[9]
Wikipedia, “Old Age,” last modified March 2, 2020, https://en.wikipedia.org/wiki/Old_age .

[10]
Our World in Data, “Life Expectancy,” accessed February 13, 2020, https://ourworldindata.org/grapher/life-expectancy .

[11]
Our World in Data.

[12]
Kathy Kessler Price, "Acoustic and Perceptual Assessments of Experienced Adult Female Singers According to Menopausal Status, Hormone Replacement Therapies,
Singing Experience, and Preferred Singing Mode" (PhD diss, University of Kansas, 2010).

[13]
Maya Dusenbery, Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick (New York: HarperOne,
2019), Introduction.

[14]
Ada McVean, “The History of Hysteria,” McGill University Office for Science and Society, July 13, 2017, https://www.mcgill.ca/oss/article/history-quackery/history-
 Ada McVean, “The History of Hysteria,” McGill University Office for Science and Society, July 13, 2017, https://www.mcgill.ca/oss/article/history-quackery/history-

hysteria .

[15]
Wikipedia, “Female Hysteria,” last modified January 11, 2020, https://en.wikipedia.org/wiki/Female_hysteria - cite_note-Maines-1 .

[16]
Louise Foxcraft, Hot Flushes, Cold Science: A History of the Modern Menopause (London: Granta Books, 2009), Introduction

[17]
McVean, “The History of Hysteria.”

[18]
Maria R. Gomez, Nada Majerníková, and Ger T. Rijkers, letter to the editor, Frontiers in Women’s Health 3, no. 4 (2018): 1, https://doi.org/10.15761/FWH.1000155 .

Chapter 1

[19]
Martha Elliott, “Singing Through Menopause: Reactions and Responses – Survey Results,” Journal of Singing 73, no. 3 (January/February 2017): 269–278.

[20]
Joan Baez, “The Big Interview with Dan Rather: Joan Baez,” interview by Dan Rather, The Big Interview, November 6, 2018, http://www.axs.tv/originals/
joanbaeztbi/ .

[21]
Kathy Kessler Price, "Acoustic and Perceptual Assessments of Experienced Adult Female Singers According to Menopausal Status, Hormone Replacement Therapies,
Singing Experience, and Preferred Singing Mode" (PhD diss, University of Kansas, 2010).

[22]
Mayo Clinic, “Menopause,” August 7, 2017, https://www.mayoclinic.org/diseases-conditions/menopause/symptoms-causes/syc-20353397?page=0&citems=10 .
[23]
Linda Wise, “Essay Voice and Soul – The Alfred Wolfsohn/Roy Hart Legacy,” Voice and Speech Review 5, no. 1 (2007): 45-52, https://doi.org/
10.1080/23268263.2007.10769740 .

[24]
Sasha Ingber, “Rohingya Refugees Create Music to Memorialize Culture For Future Generations,” NPR Music , January 26, 2019, https://www.npr.org/
2019/01/26/688976787/rohingya-refugees-create-music-to-memorialize-culture-for-future-generations.

Chapter 2

[25]
Mayo Clinic, “Type 2 Diabetes,” January 9, 2019, https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193 .

[26]
Sarah Wilson, “How Music Works: What Happens to Your Brain When You Sing?” By Matthew Lorenzon, Classic FM, August 13, 2018, https://www.abc.net.au/
classic/features/how-music-works-what-happens-to-your-brain-when-you-sing/10115596 .

[27]
Linda Wasmer Andrews, “Hum a Happy Tune for Wellness,” Psychology Today, November 21, 2011, https://www.psychologytoday.com/us/blog/minding-the-body/
201111/hum-happy-tune-wellness .

[28]
Wilson, “How Music Works.”

[29]
Daisy Fancourt et al., “Singing Modulates Mood, Stress, Cortisol, Cytokine and Neuropeptide Activity in Cancer Patients and Careers,” ecancermedicalscience 10, no.
631 (April 2016): 1-13, http://dx.doi.org/10.3332/ecancer.2016.631 .

[30]
Sarah Claydon, “The Science Behind Why Choir Singing is Good for You,” CBC (blog), March 29, 2018, https://www.cbc.ca/radio/blogs/the-science-behind-why-choir-
singing-is-good-for-you-1.4594292 .
[31]
Lynnette Leidy Sievert, Nicole Jeff, and Nancy Fugate Woods, “Stress and Midlife Women’s Health,” Women’s Midlife Health 4, no. 4 (March 2018): 1-5, https://
doi.org/10.1186/s40695-018-0034-1 .

[32]
National Sleep Foundation, “How to Handle Obstructive Sleep Apnea During Menopause,” SleepFoundation.org, accessed January 31, 2020, https://
www.sleepfoundation.org/articles/how-handle-obstructive-sleep-apnea-during-menopause .

[33]
Andrew Weil, “Coping with the Creepy Crawlies?” WEIL, May 10, 2008, https://www.drweil.com/health-wellness/health-centers/women/coping-with-creepy-crawlies/
.

[34]
Elisa Monti, prod., You'll Say Nothing: A Documentary Project on the Relationship Between Trauma and Voice, 2017, https://vimeo.com/196587758# .

Chapter 3

[35]
Kathy Mattea, “How Kathy Mattea Got Her Voice Back with ‘Pretty Bird.’” interview by Alyssa Edes, Mary Louise Kelley, and Emily Kopp. NPR Music Interviews .
September 19, 2018. https://www.npr.org/2018/09/19/649318596/how-kathy-mattea-got-back-her-voice-with-pretty-bird

[36]
Cleveland Clinic, “Menopause, Perimenopause and Postmenopause,” updated December 24, 2019, https://my.clevelandclinic.org/health/diseases/15224-menopause-
perimenopause-and-postmenopause .

[37]
Jenna Fletcher, “How Does the Mirena Coil Affect Menopause?” Medical News Today, November 5, 2019, https://www.medicalnewstoday.com/articles/326904 .

[38]
Nicole Galan, “How Do Birth Control Pills Affect Menopause?” Medical News Today, June 14, 2018, https://www.medicalnewstoday.com/articles/322133 .
[39]
Emily Vaughn and Rhitu Chatterjee, “Menopause Can Start Younger Than You Think: Here’s What You Need to Know,” Shots Health News from NPR, January 18,
2020, https://www.npr.org/sections/health-shots/2020/01/18/797354824/menopause-starts-younger-than-you-think-heres-what-you-need-to-know .

[40]
RedHotMamas, “Menopause Symptoms,” May 28, 2014, https://redhotmamas.org/menopause-a-z/common-symptoms/ .

[41]
Martha Elliott, “Singing Through Menopause: Reactions and Responses – Survey Results,” Journal of Singing 52, no. 4 (March/April 1996): 39-42.

[42]
Bioidentical hormones have a chemical composition that is identical to that of hormones produced by the body. FDA-approved bioidentical hormones are
manufactured in standardized dosages.

[43]
Daniel Boone, The Voice and Voice Therapy, 3 rd ed. (Englewood Cliffs, NJ: Prentice Hall, Inc., 1983), 39.

[44]
Tamara Bernstein, “Is the Opera House Hot or Is It Just Me? (Effects of Menopause on the Voice),” Classical Singer 18 (March 2005): 26-29.

[45]
Jean Abitbol, Patrick Abitbol, and Beatrice Abitbol, “Sex Hormones and the Female Voice,” Journal of Voice 13, no. 3 (September 1999): 424-446.

[46]
Abitbol, “Sex Hormones.” Also see Sameep Kadakia, Dave Carlson, and Robert T. Sataloff, “The Effects of Hormones on the Voice,” Journal of Singing 69, no. 5
(May/June 2013): 571-574; Kate A. Emerich, Cheryl Hoover, and Robert Sataloff. “The Effects of Menopause on the Singing Voice.” Journal of Singing 52, no. 4 (March/
April 1996): 39-42.; Berit Schneider et al., “Voice Impairment and Menopause,” Menopause: The Journal of the North American Menopause Society 11, no. 2 (March-
April 2004): 151-158.

[47]
OBOS Menopause Contributors, “What to Expect in Perimenopause,” Our Bodies Ourselves , October 15, 2011, https://www.ourbodiesourselves.org/book-excerpts/
health-article/what-to-expect-perimenopause/ .
[48]
Yolanda Heman-Ackah, “Hormone Replacement Therapy: Implications of the Women’s Health Initiative for the Perimenopausal Singer,” Journal of Singing 60, no. 5
(May/June 2004): 471-475.

[49]
Elliott, “Singing Through Menopause.”

[50]
Barbara Fox DeMaio, “The Effects of Menopause on the Elite Singing Voice: Singing Through the Storm,” DMA diss, Shenandoah University, 2013, June 26, 1983.

[51]
Chorus America, “The Corus Impact Study: Singing for a Lifetime,” June 27, 2019, https://www.chorusamerica.org/resource/chorus-impact-study-singing-lifetime .

[52]
Elliott, “Singing Through Menopause.”

[53]
Jean Abitbol. The Female Voice. (San Diego: Plural Publishing, 2019), xi, xii.

Chapter 4

[54]
Robert Edwin, “Voice Pedagogy for the Aging Singers (Including the Author), Journal of Singing 68, no. 5 (May/June 2012): 561–563.

[55]
Charles W. Schmidt, “Age at Menopause: Do Chemical Exposures Play a Role?” Environmental Health Perspectives 125, no. 6 (June 2017): 062001-1-062001-5,
https://doi.org/10.1289/EHP2093 .
Chapter 5

[56]
Tamara Bernstein, “Is the Opera House Hot or is it Just Me? (Effects of Menopause on the Voice),” Classical Singer 18 (March 2005): 26-29.

[57]
North American Menopause Society, "How Do I Know I’m In Menopause?” accessed February 13, 2020, https://www.menopause.org/for-women/menopauseflashes/
menopause-symptoms-and-treatments/how-do-i-know-i%27m-in-menopause-

[58]
Leda Scearce, Manual of Singing Voice Rehabilitation: A Practical Approach to Vocal Health and Wellness (San Diego: Plural Publishing, 2016) , 33.

[59]
Scearce, Manual of Singing, 33.

[60]
American Academy of Otolaryngology – Head and Neck Surgery, “Vocal Cord (Fold) Paralysis,” ENThealth, last reviewed August 2018, https://www.enthealth.org/
conditions/vocal-cord-fold-paralysis/ .

[61]
American Thyroid Association: General Information / Press Room, accessed February 13, 2020, https://www.thyroid.org/media-main/press-room/ .

[62]
Nicole Galan. “Is There a Link between Menopause and an Underactive Thyroid?” Medical News Today. March 20, 2018. https://www.medicalnewstoday.com/
articles/320130 .

[63]
Daniel Ruiz and Michael Okoreeh, eds., “Autoimmune Disease,” Hormone Health Network, last updated October 2019, https://www.hormone.org/diseases-and-
conditions/autoimmune-disease .
[64]
Searce, Manual of Singing, 61-62.

[65]
Cleveland Clinic, “Laryngopharyngeal Reflux (LPR),” updated September 20, 2018, https://my.clevelandclinic.org/health/diseases/15024-laryngopharyngeal-reflux-lpr .

[66]
Mary T. Infantino, “The Prevalence and Pattern of Gastroesophageal Reflux Symptoms in Perimenopausal and Menopausal Women,” Journal of the American
Academy of Nurse Practitioners 20, no. 5 (June 2008): 266-272, https://doi.org/10.1111/j.1745-7599.2008.00316.x .

[67]
Stephen L. Betts, “Kathy Mattea on New Album, Voice Struggles, Grappling with Loss.” Rolling Stone. October 1, 2018. https://www.rollingstone.com/music/music-
country/kathy-mattea-interview-pretty-bird-voice-trouble-731403/

[68]
Sara Gottfried, “Aging Reset” (online course, Reset 360), accessed May 2019, https://shop.reset360.com/pages/aging-reset-younger-program .

Chapter 6

[69]
DeLisa Fairweather and Noel R. Rose, “Women and Autoimmune Disease,” Emerging Infectious Diseases 10, no. 11 (November 2004): 2005-2011. https://doi.org/
10.3201/eid1011.040367 .

[70]
Maya Dusenbery, Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick (New York: HarperOne,
2019), Introduction.

[71]
Jenny Hole et al., “Music as an Aid for Postoperative Recovery in Adults: A Systematic Review and Meta-analysis,” The Lancet 386, no. 10004 (October 2015):
1659-1671, https://doi.org/10.1016/S0140-6736(15)60169-6 .
[72]
Jing Kang, Jack J. Jiang, and Austin Scholp, “A Review of the Physiological Effects and Mechanisms of Singing,” Journal of Voice 32, no. 4 (July 2018): 390-395.
https://doi.org/10.1177/1029864916644486 . Also see Jeanette Tamplin et al., “ParkinSong: A Controlled Trial of Singing-Based Therapy for Parkinson’s Disease,”
Neurorehabilitation and Neural Repair 33, no. 6 (June 2019): 453-463, https://doi.org/10.1177/1545968319847948 .

[73]
Jeffrey Borenstein, Scott C. Anderson, and Christopher Bergland, “What is the Vagus Nerve?” Psychology Today (blog), accessed February 8, 2020, https://
www.psychologytoday.com/us/basics/vagus-nerve .

Chapter 7

[74]
Wikipedia, "Light Therapy,” last modified March 6, 2020, https://en.wikipedia.org/wiki/Light_therapy .

[75]
Wikipedia, “Light Therapy.”

[76]
Beverly Rubik, Dr. Beverly Rubik, accessed November 15, 2019, https://www.brubik.com .

[77]
T.S. Rao Sathyanarayana et al., “The Biochemistry of Belief,” Indian Journal of Psychiatry 51, no. 4 (October-December 2009): 239-241, https://doi.org/
10.4103/0019-5545.58285 .

[78]
Shamini Jain et al., “Clinical Studies of Biofield Therapies: Summary, Methodological Challenges, and Recommendations,” Global Advances in Health and Medicine 4,
no. 1 (January 2015): 58-66, https://doi.org/10.7453/gahmj.2015.034.suppl .

[79]
Meribeth Bunch Dayme, Dynamics of the Singing Voice, 3 rd ed. (Springer-Verlag/Wien, 1995), 151.
[80]
Joseph Bennington-Castro, “How Horses Help with Mental Health Issues,” Everyday Health, updated December 18, 2014, https://www.everydayhealth.com/news/
how-horses-help-with-mental-health-issues/ .

[81]
Laura Johannes, "The Intriguing Health Benefits of Qigong,” The Wall Street Journal, September 30, 2013, 6:52 p.m. EST, https://www.wsj.com/articles/the-
intriguing-health-benefits-of-qigong-1380581455 .

[82]
Eva Selhub, “The Alexander Technique Can Help You (Literally) Unwind,” Harvard Health Publishing (blog), November 23, 2015, https://www.health.harvard.edu/blog/
the-alexander-technique-can-help-you-literally-unwind-201511238652 .

[83]
Society of Teachers of the Alexander Technique, “Research Directory,” accessed February 5, 2020, https://alexandertechnique.co.uk/alexander-technique/research/
listing .

[84]
Paul Offit, Do You Believe in Magic: The Sense and Nonsense of Alternative Medicine (New York: Harper Collins, 2013), Introduction.

Chapter 8

[85]
Martha Howe, A User’s Manual for the Aging Voice (Devon, UK: Compton Publishing, 2019), 152, 149.

[86]
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[117]
Androgens (testosterone) were and are still sometimes suggested as part of menopausal hormone therapy for women, and they may be used in certain medical
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Table of Contents

TITLE PAGE
Copyright
Copyright
Copyright
Dedication
Foreword
Contents
INTRODUCTION
EMPOWERING WOMEN WHO SING
PERSIST IN SINGING
HORMONE RELATED MIDLIFE VOICE CHANGES
SMOOTH SAILING
ROUGH WATERS
SINGING THROUGH THE HARD TIMES
EXPLORING ALTERNATIVE METHODS
FINDING YOURSELF ON THE OTHER SIDE
SINGING INTO OLDER AGE
WHERE TO GO FROM HERE
Appendices
Acknowledgments
Bibliography
About the Authors
Endnotes