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Perceived Effects of the Menstrual Cycle on Young Female Singers in the

Western Classical Tradition

Article in Journal of voice: official journal of the Voice Foundation · August 2007
DOI: 10.1016/j.jvoice.2007.05.004 · Source: PubMed

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Perceived Effects of the Menstrual Cycle on Young
Female Singers in the Western Classical Tradition
Maree Ryan and Dianna T. Kenny University of Sydney, New South Wales, Australia

Summary. This study investigated the perceived effects of the female hormonal cycle on young female classical
singers. All the singers, including male controls, were tertiary singing students from the Sydney Conservatorium of Mu-
sic, Australia, who were selected for entry into vocal study programs by competitive audition. Female participants com-
pleted a questionnaire and daily diary in the first and third months of the study. Male controls completed the diary for the
first month only. The questionnaire and diary focused on singers’ physical symptoms, their mood states, and vocal pro-
duction. Analysis of the diaries indicated that although 81% of female singers reported regular menstrual cycles and
43% reported using an oral contraceptive, neither of these factors was related to the voice quality variables as measured
on the first day of the cycle. Singers who were not taking a contraceptive pill rated their voice quality lower and their
mood higher than those on the pill. There was no relationship between temperature recording in the females and day of
cycle. Perceived voice quality for female singers was lower on days 1–3 compared to the remainder of the cycle and
there was a trend for ratings to improve through days 1–7. The voice parameters for male singers tended to be slightly
flatter over the cycle days than for females. Although voice quality in females indicated a tendency to be lower on av-
erage during days 24–4 of the cycle, voice quality for males tended to be more alike during the two phases, days 24–4
and days 5–23. Overall, reduced voice quality was associated with more negative mood experiences. The six most se-
verely affected females completed voice recordings of specific vocal tasks on the first day of the cycle and again in mid-
cycle. These recordings were randomly presented to both the participants and expert vocal pedagogues to ascertain
whether significant differences in vocal quality were perceptually identifiable. Singers, but not pedagogues, were
able to accurately identify the timing of the recordings. Although the singer recognized that greater effort is required
to produce the sound during menstruation, discernible differences were not detected by expert listeners.
Key Words: Menstrual cycle–Classical singing–Vocal quality–Perceptual effects.

INTRODUCTION
The relatively few studies to date that have investigated the ef-
fect of the hormonal cycle on female singers have generally
used subjects who were untrained singers and tasks that do
not challenge the vocal instrument. The use of untrained singers
does not provide information important to professional singers
who use their vocal instrument in a much more demanding way
with respect to pitch, dynamic range, and duration, and who
perform more complex vocal motor tasks than speakers or un-
trained singers singing simple tunes. These methodological is-
sues notwithstanding, all the studies to date support the
hypothesis that the voice is affected by the menstrual cycle
via the hormonal and physiological changes that occur during
this time. The results of most of these early studies, which are
summarized below, cannot be generalized to professional fe-
male singers, hence the need for the current study.
One of the earliest studies1 assessed the presence of premen-
strual hoarseness in two groups of undergraduate majors, aged
19–36 years, with normal speaking voices, but no vocal train-
ing. None of the subjects was on the contraceptive pill and
all took their daily basal temperature to plot the hormonal
changes. The vocal tasks used were speech samples of 3-sec-
Accepted for publication May 10, 2007.
From the Australian Centre for Applied Research in Music Performance (ACARMP),
Sydney Conservatorium of Music, University of Sydney, New South Wales, Australia.
Address correspondence and reprint requests to Professor Dianna T. Kenny, Director,
Australian Centre for Applied Research in Music Performance (ACARMP), Sydney Con-
servatorium of Music, The University of Sydney, New South Wales, Australia 2006.
E-mail: d.kenny@usyd.edu.au
Journal of Voice, Vol. 23, No. 1, pp. 99-108
0892-1997/$36.00
Ó 2009 The Voice Foundation
doi:10.1016/j.jvoice.2007.05.004
ond duration using the vowels ‘‘ah,’’ ‘‘eu,’’ and ‘‘u.’’ Two
samples were taken, one at ovulation and the other at premen-
struation. Results indicated that participants showed no ten-
dency to become hoarse at premenstruation and this was
replicated in a second group of women. The data did not sup-
port the contention that hoarseness was a feature typical of pre-
menstruation, as both series demonstrated no difference
between hoarseness at premenstruation and hoarseness at ovu-
lation. Among European opera singers, the belief that hoarse-
ness occurred at premenstruation had resulted in contracts
containing clauses to exempt them from singing during that pe-
riod of their monthly cycle.
Higgins and Saxman2 assessed the speech samples (six
vowels) of 10 young women and five young men aged 19–26
years, all untrained singers, to assess hormonal effects on voice
in females and to show that the vocal output alters because the
mass of the vocal folds changes. None of the female subjects
was taking the contraceptive pill. Basal temperature of the
women was recorded daily to reveal ovarian hormonal fluctua-
tion. Testing occurred every second day for 33 days. Results in-
dicated that at the premenstruum and during the onset of
menstruation, the magnitude of frequency perturbation (distur-
bance) was not notably different from the average behavior of
individual subjects, in that it did not change, when the predic-
tion was that the fundamental frequency would decrease. How-
ever, ovulation was associated with notable changes, both
upward and downward, in the magnitude of frequency perturba-
tion for most subjects, supporting the idea that large fluctuations
in hormonal levels affect vocal fold stability. Conversely, larger
frequency perturbations were found for young men than for
women in this investigation.
100
The results of neither of these earlier studies can be general-
ized to the classical singing voice. Although vocal testing (ie,
reading, singing chromatic scales and phrases, as well as low
and high sustained notes) used by Brown et al3,4 was appropri-
ate for assessment of professional singers, the study used
a mixed sample of 16 women aged between 18 and 22 years,
some of whom were trained singers and some of whom had
no singing training. No information as to which results be-
longed to which group was given so that no conclusions could
be drawn with respect to singers. A number of other methodo-
logical problems with this study render the results uninterpret-
able. For example, only participants with irregular menstrual
cycles were included, so that results could not be generalized
to all women. Irregular menstrual cycles generally show more
hormonal fluctuations and greater negative impact on the
voice.3,4 Some of the women were taking the contraceptive
pill but no subgroup analysis of this subsample was reported.
The contraceptive pill eliminates hormonal fluctuations and
hence vocal instability is either reduced or eradicated.5
Chae et al6 evaluated whether the presence of premenstrual
syndrome (PMS) affects female singers and assessed 28 women
over a 2-month period. Participants were female nurses aged 21–
30 years, all untrained singers. Their task involved the produc-
tion of 5 seconds of sustained sound on the ‘‘ah’’ (as in ‘‘father’’)
vowel. None of the participants took the contraceptive pill and
none was consistent in taking their daily basal temperature to
plot their monthly hormonal changes. Chae et al6 hypothesized
that PMS can predict the extent of voice change during the pre-
menstrual phase but found that the change in the voice was re-
lated to the presence of PMS, and not its severity. However,
testing such as this is inadequate for singers and is more relevant
to the speaking voice, although the methodological problems
were such that they made any conclusions difficult.
Abitbol et al7 tested 97 women with vocal PMS, all vocal pro-
fessionals aged 23–36 years. None was taking the contraceptive
pill and all presented with a premenstrual dysphonia. Estrogen
and progesterone levels were measured and vocal fold smears
and cervical smears were taken. The vocal stimulus was Fre`re
Jacques, a French folk song, and although more challenging
than speaking or sustaining vowels, it is still far removed in dif-
ficulty from the daily expectations of a professional singer, as it
has limited pitch range, volume expectation, or technical chal-
lenge. The results indicated that in the premenstrual phase, all
the subjects showed physical signs of change in the vocal folds
that disturbed vibratory and muscle function. Stroboscopy re-
vealed asymmetric vocal fold vibrations, whereas associated
spectrographic signs showed loss of certain harmonics and
change in laryngeal kinetics. They concluded that the four clin-
ical signs related to the voice—vocal fatigue, decreased range
(including loss of high tones and of pianissimo), loss of vocal
power, and loss of certain high harmonics (more metallic and
huskier voice)—apart from other signs such as irritability, ner-
vousness, and pelvic pain were part of the vocal PMS.
Abitbol et al7 studied 100 menopausal women including 17
who presented clinically with the vocal syndrome of meno-
pause, a condition wherein androgen action is virtually unop-
posed by estrogen effects. The signs noted were lowering of
Journal of Voice, Vol. 23, No. 1, 2009
vocal intensity, vocal fatigue, decreased range with loss of
high notes, and loss of timbre in spoken and singing voice.
All these women had ceased menstruation and were not under-
going hormone replacement therapy. The vocal syndrome is
progressive and is especially observed in voice professionals
of all genres, who complain of loss of high notes, alteration
in pianissimos, loss of harmonics, and reduced color of their
voices. In addition, vocal fold and cervical smears showed
a striking resemblance, indicating that the mucosal lining of
both regions is similar and show similar changes such as muco-
sal atrophy from androgen effects.
Finally, in the study by Wicklund,8 a group of 20 women
aged 20–57 years were selected to assess the relationship be-
tween PMS and vocal dysphonia. The wide age range is prob-
lematic because different factors affect women at different
ages, producing different symptoms. Many women in the inter-
mediate and older age groups may have borne children, which
affect hormones, and some of those approaching 50 years of age
may have been menopausal. The average age of menopause is
between 45 and 55 years and there are many symptoms that re-
flect hormonal changes up to 5 years before menopause, so it is
plausible that several of these subjects may have been inappro-
priate subjects. However, there was an excellent questionnaire
on PMS, in which several areas such as mood states, voice dif-
ferences, and general health were addressed, as well as specific
questions covering premenstrual dysphonia. Questions on gen-
eral health included sleeping patterns, food cravings, head-
aches, smoking habits, and exercise programs. In addition,
acoustic and glottographic testings were conducted. Results in-
dicated that the severity levels of PMS and menstrual dysphonia
may be linked.
The effect of exercise on symptoms and dysphonia could not
be accurately assessed because of the small sample size.
Many observers have reflected on the mood states investi-
gated in Wicklund’s research. Chae et al6 observed that one
or more of the four emotional components—sadness, tension,
anxiety, or conflict—are present along with the diagnostic cri-
teria for PMS. Davis and Davis9 stated that the larynx is espe-
cially sensitive and vulnerable to fatigue and that an emotion
such as anger will adversely affect the voice. Sommer,10 in
her paper on stress and menstrual disorder, described women
from many published papers reporting unpleasant symptoms
such as stress, irritability, nervousness, and depression associ-
ated with the premenstrual and menstrual phases of the cycle.
The aim of this study was to investigate, using appropriate
sampling, design, and measures, the variability of the singing
voice over the menstrual cycle and its perceived effects on
singers and expert listeners in order to add to the literature on
the effects of hormonal fluctuations on the young professional
female singer.
Women are known to suffer from premenstrual symptomatol-
ogy to varying degrees as ascertained from a large body of liter-
ature.11 A diagnosis of PMS is only established if symptoms
resolve for at least the days between the end of the menstrual pe-
riod and ovulation, that is, approximately days 7–14 of the cycle.
Nader12 identified significant individual cyclical variation in
symptomatology surrounding the menstrual cycle, with
Maree Ryan and Dianna T. Kenny Does Menstrual Cycle Affect Female Classical Singers’ Voices?
premenstrual symptoms varying from mild to severe. About
30%–40% of women experience some form of premenstrual
symptoms, and 10% of women experience severe symptoms.
Nader12 classified the signs and symptoms of the syndrome
into somatic (body states), affective (mood states), pain and be-
havioral states, and other symptoms, such as food cravings, in-
somnia, and fatigue. The participants recorded a daily diary
related to the menstrual cycle, with physical symptoms based
on those most commonly described in the literature.8,12
METHOD
The study was conducted in two phases. In the first phase, the
whole sample recorded required information in daily diaries.
In the second phase, a subset of six female singers made voice
recordings at different stages of the menstrual cycle for percep-
tual assessment by expert judges.
Phase 1
Participants. A total of 27 singers, of whom six were male
and 21 were female, provided sufficient data to be included in
longitudinal analyses. Of the six males, five completed the daily
diaries for 28 days and one completed the diary for 26 days; we
used males in the study to assess variations in mood and self-
perceived voice quality in the absence of obvious hormonal ef-
fects experienced by female singers. Of the 21 females, 14 com-
pleted the diaries for 28 days, three for 27 days, three for 25
days, and one for 18 days.
No hormonal tests were conducted on any subject in the
study because of the cost and intrusive nature of such tests.
The male recording commenced on a random day 1, as opposed
to the physiological day 1 in the female cycle. To include
singers in longitudinal analyses, missing values were replaced
by the singer’s mean value for their cycle but missing data
were not replaced past the last day of recording.
Other medical history were not taken into consideration in
the student diaries, but the authors knew by direct association
with the participants that there was one type 1 diabetic student,
one other with insulin resistance, and one female recently diag-
nosed with hypothyroidism.
Measures. The daily diary and questionnaire were custom-
designed for this study and covered questions on physical
symptoms, voice, and mood states. Diaries were bound in
Thinking about your singing today, to what extent do you agree or disagree with the following:
My voice felt in peak form
My voice felt fatigued
It took a lot of effort to sing
My ability to support my sound was affected
My voice seemed hoarse or husky
My voice felt muffled, weak or breathy
I could not extend to the top of my range
I was not able to control my voice as easily
My voice felt “sluggish”
My voice sounded flat in pitch
FIGURE 1. Questionnaire on vocal quality.
101
36-page booklets. Participants were asked to complete one
page per day for each day of the observation period.
The female participants were asked to record their daily tem-
perature and their menstrual cycles over 2 noncontiguous
months of data, whereas male volunteers who were used as con-
trols completed 1 month’s data. The females in our research
were asked to record whether they were using hormonal contra-
ception and other symptoms such as intercurrent illness, unre-
lated physical symptoms, for example, body pain, and alcohol
intake were also recorded, as such factors could influence voice
production and quality.
We selected 2 noncontiguous months’ data for diary data col-
lection because we did not want to burden busy participants, as
most researchers acknowledge, the longer and harder the task,
the lower the compliance; secondly, the break of 1 month be-
tween diary keeping would reduce recall and duplication effects.
Questionnaire on vocal quality. Items included in the question-
naire used to rate voice quality were selected on the basis that
they are commonly used by vocal pedagogues and students to
describe the voice and which occurred in the literature as de-
scriptors of vocal health and quality.7,13–15 Participants rated
the items on a 10-cm visual analog scale (VAS) with the anchors
strongly agree and strongly disagree (Figure 1). Negatively
worded items were reverse scored, so higher scores indicated
more positive ratings of vocal quality.
Profile of Mood States. Words used to describe mood states
were selected from each of the subscales of the Profile of Mood
States (POMS).16 Other vocal researchers9,17,18 have taken a sim-
ilar approach to mood description in vocal research (Figure 2).
Temperature chart. The temperature chart was based on the
chart used by the Family Planning Association of Australia
and modified to suit the current study. Recording of basal tem-
perature and change, and ‘‘ovulation shift,’’ during the female
menstrual cycle followed protocols based on current practice
and previous studies.19–21
Phase 2
Participants. Singers. The six female singers who reported
being most affected by their hormonal fluctuations in the diary
study participated in this phase of the study. Of those most af-
fected by their cyclical symptoms, four were not taking the
Strongly disagree Strongly agree
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
102 Journal of Voice, Vol. 23, No. 1, 2009

Below is a list of feelings that people have. For each feeling, cross ONE number for the answer
that best describes HOW YOU ARE FEELING RIGHT NOW. The numbers refer to these phrases

0 = Not at all, 1 = A little, 2 = Moderately, 3 = Quite a lot, 4 = Very

Relaxed (0) (1) (2) (3) (4)

Discouraged (0) (1) (2) (3) (4)
Annoyed / Irritable (0) (1) (2) (3) (4)
Sad / depressed (0) (1) (2) (3) (4)
Unable to Concentrate (0) (1) (2) (3) (4)
Energetic (0) (1) (2) (3) (4)
Forgetful / confused (0) (1) (2) (3) (4)
Tense / anxious (0) (1) (2) (3) (4)
Exhausted (0) (1) (2) (3) (4)
Cheerful (0) (1) (2) (3) (4)
Angry (0) (1) (2) (3) (4)
Fatigued (0) (1) (2) (3) (4)
Happy (0) (1) (2) (3) (4)

FIGURE 2. Items from the Profile of Mood States (POMS) used to assess mood.

pill and two were using oral contraception, yet only one in each
subgroup recorded an obvious temperature rise. Their voices,
using specific tasks, were recorded at two points in the monthly
cycle (day 1 and midcycle, between days 10 and 14). The taped
samples were randomly aggregated onto a CD and both expert
pedagogues and the singers rated the vocal quality of the sam-
ples on a vocal-quality rating scale to ascertain whether there
were any discernible differences in the voice production at these
times. The singers also indicated whether the sample was taken
during menses or at midcycle.
Perceptual judges. Six voice teachers who were expert vocal
pedagogues acted as judges of the vocal recordings. Their expe-
rience was wide-ranging and included significant international
performing careers and Australian- and overseas-acquired aca-
demic qualifications.
Vocal recordings. The musical task recorded was 20 sec-
onds of an aria, O Mio Babbino Caro from the opera, Gianna
Schicchi by Puccini. This extract challenged each singer in
range extension, sustained support of the voice, accuracy of in-
tonation (pitch), flexibility of phrasing and movement through
the registers, and language facility.
We recorded arpeggios and other scale patterns and messa di
voce at each session, but final analysis was confined to the aria
extract as it revealed all the information appropriate to this
study. Both musical tasks were chosen as specific to the singing
voice, in contrast to previous studies conducted on speaking and
singing voices. This was a significant methodological advance
in that vocal effects of the menstrual cycle might only be ob-
served at the extreme range or technical challenge of the vocal
stimulus. The nearest tests to western classical singing in previ-
ous studies, that is, chromatic scales and phrases22 and Fre`re
Jacques,7 were both tasks that are too far removed in difficulty
from the daily expectations of a professional singer who re-
quires wider range and greater volume in pieces of music of
much greater technical challenge.
RESULTS
Phase 1
Statistical methods. Linear mixed models were used to
measure the independent effects of cycle (days 24–4 compared
with days 5–23), gender, and contraceptive pill use on voice
quality and mood. The effect of contraceptive pill use was
tested in females only. An autoregressive covariance matrix
was used to allow for values closer together to be more corre-
lated than values further apart. This covariance structure pro-
vided a lower 2 restricted log likelihood than either an
unstructured matrix or a compound symmetry matrix and was
therefore used in the mixed models. The residual values for
the models were normally distributed with no major outliers
and therefore assumptions for the models were met. Repeated
measures general linear models were then used to examine
trends using a linear polynomial contrast in mood and voice
quality over the first four days of the cycle. In addition, devia-
tion contrasts were used in females to identify days where
values were significantly higher or lower than the mean value
for all time points. There was insufficient data to undertake
this analysis in males. Relationships between voice quality
measurements and mood were examined using Pearson’s corre-
lation coefficients.
Descriptive analyses. The characteristics of the 27 singers
are shown in Table 1. None of the female singers was pregnant
and four reported having an irregular menstrual cycle.
Table 2 shows the effects of gender and cycle (days 24–4
compared to days 5–23) on voice quality and mood. The
mean scores for males tended to be higher than those for fe-
males for all variables except range and mood and the standard
errors were also higher in males indicating a wider range used
on each scale. There was a significant difference in peak form
between males and females (P < 0.0001) and a marginally sig-
nificant difference in weak (P ¼ 0.07) and sluggish voice
(P ¼ 0.07), with males scoring higher on all measurements.
Maree Ryan and Dianna T. Kenny Does Menstrual Cycle Affect Female Classical Singers’ Voices? 103

fatigued voice (P ¼ 0.07). The table also shows the estimated

TABLE 1.
Characteristics of Singers
mean values for cycle in females only after adjusting for the in-
fluence of contraceptive pill use. After adjusting for the effect of
Total Sample taking a contraceptive pill, the mean values for all voice mea-
Males Females surements again tended to be lower and mood tended to be
worse (higher score) in cycle days 24–4 than in cycle days 5–
Total number 6 21
23 with significant differences for fatigued voice (P ¼ 0.02)
Soprano — 19 (91%) and a marginally significant difference for effort (P ¼ 0.06)
Mezzo soprano — 2 (9%) and mood (P ¼ 0.07).
Baritone 4 (67%) — The mean values for voice quality for the first phase of the
Tenor 1 (17%) — cycle (days 24–4) and the remainder of the cycle (days 5–23)
Counter tenor 1 (17%) —
are shown in Figure 3 for females and in Figure 4 for males.
Age range (y) 19–29 18–27 The figure for females indicates a tendency for all measure-
Singing (y) 3–9 2–16 ments to be approximately one point lower on average during
Oral contraceptive pill — 9 (43%) days 24–4 of the cycle, whereas for males mean values tend
Regular cycles — 17 (81%) to be more alike during the two phases except for peak form.
Table 4 shows the mean values of the voice quality parame-
ters and mood for selected days over the cycle in males and fe-
males. Females tended to score lower on all voice quality
The difference in mood did not reach statistical significance at measurements, especially on days 1 and 4, and higher on
P ¼ 0.09. mood. For mood, female scores were on average 5–6 points
The estimated marginal mean values for cycle after adjusting higher than males on days 1 and 4 but similar on days 14 and 23.
for a gender influence are also shown in Table 2. The mean The F values and P values for the repeated measures devia-
scores for voice quality tended to be lower as indicated by the tion contrasts are shown in Table 4. Mean values for voice qual-
negative values for mean difference, and mood tended to be ity measurements were lower on day 1 of the cycle for females
higher as indicated by a positive mean difference, in cycle with significant differences for all measurements except hoarse
days 24–4 when compared with cycle days 5–23. There was or weak voice, range, and flat voice. In addition, the mean mood
a statistically significant difference for fatigued voice score was higher (worse) on day 1 (P ¼ 0.05). Also, mean
(P ¼ 0.004) and effort (P ¼ 0.03). values for all voice quality measurements except support
Table 3 shows the effects of taking a contraceptive pill and were significantly higher (better) in the center of the cycle, usu-
cycle in females. The negative mean differences for all voice ally at day 14 but at day 12 for hoarse or flat voice and at day 15
quality measurements except peak form indicate that singers for range. Mean mood score was significantly better (lower
who were not taking a contraceptive pill tended to rate lower score) at day 12 (P ¼ 0.001).
on the voice quality scores. They also rated almost two points Table 5 shows the trend test over days 1–4 for both males and
higher on mood. The difference in mean values was significant females. There was a significant trend for voice quality mea-
for hoarse voice (P ¼ 0.003) and marginally significant for surements to improve over days 1–4 in females for peak

TABLE 2.
Marginal Mean Values for Voice Quality and Mood in Males and Females and for Days 24–4 and 5–23 of Cycle Estimated
from Mixed Linear Models for Voice Quality and Mood Measurements
Gender Effect Cycle Effect
Voice
Quality Males Females Difference Days 24–4 Days 5–23 Difference
Measure Mean (SE) Mean (SE) (95% CI) P Value Mean (SE) Mean (SE) (95% CI) P Value
Peak form 6.8 (0.3) 5.4 (0.2) 1.4 (0.7,2.1) <0.0001 5.9 (0.2) 6.3 (0.2) 0.3 (0.8,0.2) 0.20
Fatigued 6.2 (0.4) 5.6 (0.2) 0.6 (0.2,1.4) 0.15 5.5 (0.3) 6.4 (0.2) 0.9 (1.4,0.3) 0.004
Effort 6.1 (0.4) 5.7 (0.2) 0.4 (0.4,1.2) 0.34 5.6 (0.3) 6.2 (0.2) 0.6 (1.2,0.1) 0.03
Support 6.3 (0.4) 6.1 (0.2) 0.2 (0.7,1.2) 0.62 6.2 (0.3) 6.2 (0.2) 0.1 (0.7,0.5) 0.83
Hoarse 7.1 (0.4) 6.5 (0.2) 0.6 (0.3,1.5) 0.21 6.6 (0.3) 7.0 (0.3) 0.3 (0.9,0.2) 0.26
Weak 7.0 (0.4) 6.2 (0.2) 0.8 (0.1,1.6) 0.07 6.6 (0.3) 6.7 (0.2) 0.1 (0.7,0.5) 0.74
Range 6.1 (0.4) 6.5 (0.2) 0.4 (1.3,0.5) 0.34 6.2 (0.3) 6.4 (0.3) 0.3 (0.9,0.3) 0.38
Control 6.8 (0.4) 6.1 (0.2) 0.7 (0.2,1.5) 0.13 6.3 (0.3) 6.6 (0.2) 0.3 (0.9,0.3) 0.25
Sluggish 7.0 (0.4) 6.2 (0.2) 0.8 (0.1,1.6) 0.07 6.4 (0.3) 6.7 (0.2) 0.3 (0.9,0.3) 0.34
Flat 7.6 (0.4) 7.0 (0.2) 0.7 (0.3,1.7) 0.17 7.3 (0.3) 7.3 (0.3) 0.1 (0.7,0.5) 0.85
Mood 14.9 (1.0) 16.9 (0.6) 2.0 (4.3,0.3) 0.09 16.6 (0.8) 15.3 (0.7) 1.3 (0.5,3.0) 0.16
Abbreviation: CI, confidence interval.
104 Journal of Voice, Vol. 23, No. 1, 2009

TABLE 3.
Marginal Mean Values for Voice Quality Measurements and Mood by Contraceptive Pill Use and Days 24–4 or Days 5–23 of
Cycle Estimated from Mixed Linear Models for Each Measurement in Females Only
Contraceptive Pill Effect Cycle Effect
Voice
Quality No Yes Difference Days 24–4 Days 5–23 Difference
Measure Mean (SE) Mean (SE) (95% CI) P Value Mean (SE) Mean (SE) (95% CI) P Value
Peak form 5.5 5.2 (0.3) 0.3 (0.4,1.1) 0.37 5.1 (0.3) 5.6 (0.2) 0.4 (1.0,0.1) 0.14
Fatigued 5.3 6.1 (0.3) 0.8 (1.6,0.1) 0.07 5.3 (0.3) 6.1 (0.2) 0.8 (1.5,0.1) 0.02
Effort 5.5 (0.3) 6.0 (0.3) 0.5 (1.3,0.3) 0.20 5.4 (0.3) 6.0 (0.2) 0.6 (1.3,0.1) 0.06
Support 5.9 (0.3) 6.3 (0.3) 0.5 (1.3,0.7) 0.49 6.1 (0.3) 6.1 (0.3) 0.1 (0.7,0.7) 0.98
Hoarse 5.9 (0.3) 7.3 (0.3) 1.3 (2.2,0.5) 0.003 6.4 (0.3) 6.8 (0.2) 0.4 (1.0,0.3) 0.24
Weak 6.1 (0.3) 6.5 (0.3) 0.4 (1.2,0.4) 0.31 6.2 (0.3) 6.4 (0.2) 0.2 (0.9,0.5) 0.57
Range 6.2 (0.3) 6.9 (0.3) 0.8 (1.6,0.1) 0.10 6.4 (0.3) 6.7 (0.2) 0.4 (1.1,0.3) 0.28
Control 5.8 (0.3) 6.4 (0.3) 0.6 (1.5,0.2) 0.15 5.9 (0.3) 6.3 (0.2) 0.4 (1.1,0.3) 0.24
Sluggish 6.1 (0.3) 6.2 (0.3) 0.1 (0.9,0.7) 0.85 6.0 (0.3) 6.4 (0.2) 0.4 (1.0,0.3) 0.30
Flat 6.8 (0.3) 7.1 (0.3) 0.3 (1.2,0.6) 0.49 7.0 (0.3) 7.0 (0.3) 0.1 (0.7,0.7) 0.87
Mood 17.8 (0.7) 16.0 (0.8) 1.8 (0.4,4.0) 0.10 17.8 (0.9) 15.9 (0.6) 1.9 (0.1,3.9) 0.07
Abbreviation: CI, confidence interval.

form, effort, support, and sluggishness but there were no trends Phase 2
for voice quality to improve over these days in males. Perceptual analysis of six female singers. Figure 5
Table 6 shows that there was a negative correlation between shows the pedagogue scores for each student during normal
voice quality and mood for all measurements on days 1, 4, 14, or menstruating phase. Variations in pedagogue scores were
and 23 indicating poor mood with reduced voice quality. Corre- wide with the smallest range of 4.7–7.1 for singer ID 21 and
lations greater than 0.43, which indicate that approximately the largest range of 1.7–5.9 for singer ID 22. There was no
40% of the variation in mood was explained by voice quality, consistent change in direction of scores during menstruating
were statistically significant. Most of the significant associa- and nonmenstruating phases with scores tending to decrease
tions occurred on days 1 and 14. for four singers and increase for one singer. As a check on con-
Mood had a stronger effect on the voice than the contracep- sistency of listener ratings, one singer provided data only dur-
tive pill, an interesting and somewhat unexpected finding. ing the nonmenstruating phase. The scores were equally
Mood improved somewhat in both males and females over variable.
days 1–7 although the trend was not statistically significant. Five of the six singers who were selected on the basis of the
The overall mood score was not significantly different between worst self-reported vocal symptoms during menstruation cor-
males and females, although males consistently rated their rectly identified their performance during menstruation when
mood as better than females. presented blind with both their recordings (one during

9 9
Days 24-4 Days 24-4
Days 5-23 Days 5-23
8 8
Mean voice quality score
Mean voice quality score

7 7

6 6

5 5

4 4
Fatigued

Effort

Support

Hoarse

Range

Control

Sluggish

Pitch
Fatigued

Effort

Support

Hoarse

Range

Control

Sluggish

Pitch

Peak

Weak
Peak

Weak

FIGURE 3. Mean unadjusted voice quality in females during days FIGURE 4. Mean unadjusted voice quality in males during days 24–
24–4 and 5–23. 4 and 5–23.
Maree Ryan and Dianna T. Kenny Does Menstrual Cycle Affect Female Classical Singers’ Voices? 105

menstruation and the other during nonmenstruation). Figure 6

TABLE 4.
Mean Values with Standard Deviations Shown in
shows the self-rated scores for each singer. Two singers (ID
Brackets for Voice Quality Measurements and Mood on 21 and 27) rated themselves consistently and highly but for
Days 1, 4, 12–15, and 23 of the Cycle the other four singers the ratings across voice quality were in-
consistent and variable.
Days
Perceptual analysis of six female singers demonstrated
Day 1 Day 4 12–15* Day 23
a wide variation in pedagogue scoring during both non-men-
Peak Females 4.1 (2.5) 5.2 (2.6) 6.1 (2.9) 5.7 (2.4) struating and menstruating phases. However, the students,
form Males 5.8 (1.8) 6.7 (1.7) 7.0 (1.4) 6.7 (1.0) who were selected based on the worst self-reported vocal symp-
Fatigued Females 4.1 (2.6) 5.2 (3.2) 6.9 (2.8) 6.7 (3.0) toms during menstruation, correctly identified their perfor-
Males 4.4 (2.6) 6.1 (2.4) 7.3 (2.8) 6.8 (1.9) mance during menstruation when presented blind with both
Effort Females 4.1 (2.8) 5.4 (3.0) 6.9 (2.6) 6.2 (2.8)
their recordings.
Males 4.9 (2.6) 6.7 (2.6) 6.7 (2.0) 4.9 (2.4) The participants were able to accurately determine the timing
of the recordings, whereas the pedagogues were unable to dis-
Support Females 3.9 (2.8) 5.7 (3.1) 6.8 (2.4) 6.4 (3.2) cern any difference in vocal quality between the two samples.
Males 4.2 (3.4) 6.1 (2.5) 6.5 (3.4) 6.3 (2.1)
Hoarse Females 5.3 (3.1) 5.8 (3.2) 7.5 (2.1) 7.3 (2.9)
Males 7.7 (1.3) 7.0 (2.9) 7.6 (2.9) 7.3 (2.0) DISCUSSION
Weak Females 5.2 (3.1) 5.9 (3.2) 7.0 (2.9) 6.2 (3.2) This study examined the effect of the menstrual cycle on the
Males 6.5 (2.5) 7.5 (1.5) 8.0 (1.4) 6.7 (2.1) western female classical singing voice. Participants were sing-
Range Females 4.9 (3.5) 5.8 (3.8) 7.6 (2.1) 7.1 (3.1) ing students studying at the Sydney Conservatorium of Music,
Males 6.3 (3.4) 5.4 (2.2) 6.1 (3.7) 6.3 (3.2) The University of Sydney. Twenty-one young western female
students and six young male singing students between 18 and
Control Females 4.5 (3.2) 5.8 (3.4) 7.2 (2.9) 5.6 (3.6)
28 years of age kept diaries of their perceived vocal quality
Males 5.9 (2.5) 6.5 (2.8) 6.6 (3.2) 6.7 (2.8)
and mood state every day for 1 (male) or 2 months (female).
Sluggish Females 4.6 (3.3) 6.2 (3.0) 7.1 (2.9) 5.7 (3.2) Analysis of the diaries showed large variations in female
Males 6.2 (3.0) 6.6 (3.0) 7.3 (2.8) 7.1 (2.3) symptomatology throughout the cycle with some singers re-
Pitch Females 6.3 (3.2) 6.7 (2.9) 7.1 (2.9) 6.6 (3.5) porting no significant adverse effects of their cycle, while others
Males 7.2 (2.5) 7.7 (2.1) 7.6 (3.6) 8.3 (2.3) reported a range of problems from mild to severe symptoms and
perceived reductions in their vocal quality, particularly during
Mood Females 22.0 (12.7) 19.1 (9.7) 13.5 (7.2) 16.9 (8.9)
Males 14.2 (7.9) 12.7 (5.4) 12.3 (5.9) 16.3 (7.2)
the first 7 days of the cycle. Similarly, Smith23 found that symp-
toms observed premenstrually also occur at other times in the
* The highest mean value over the 4 days is shown, usually day 14 as
shown in Table 5.
cycle but they do not necessarily occur in every cycle and do
not occur in all women.

TABLE 5.
F Value and P Value Statistics from General Linear Repeated Measures Models to Identify Lowest and Highest Days of Cycle
in Females Only and for Trends Over Days 1–4 of Cycle in Both Males and Females
Day 1* Days 12–15* Days 1–4 Trendy Days 1–4 Trendy

Females Females Females Males

Voice Quality F Value P Value Day F Value P Value F Value P Value F Value P Value
Peak form 4.7 0.06 14 6.8 0.03 5.2 0.03 3.9 0.11
Fatigued 7.5 0.02 14 25.5 0.001 2.0 0.17 3.9 0.11
Effort 9.7 0.01 14 12.7 0.01 4.4 0.05 0.3 0.64
Support 19.7 0.001 14 2.5 0.15 4.5 0.05 2.2 0.20
Hoarse 2.5 0.15 12 11.7 0.01 1.2 0.29 0.1 0.75
Weak 1.7 0.23 14 8.3 0.02 1.6 0.22 1.6 0.30
Range 2.4 0.15 15 6.1 0.03 1.1 0.30 0.7 0.43
Control 4.2 0.07 14 6.0 0.04 1.7 0.21 0.1 0.83
Sluggish 8.0 0.02 14 6.7 0.03 5.1 0.04 0.1 0.88
Flat 1.6 0.23 12 9.4 0.01 0.1 0.72 0.4 0.56
Mood 4.9 0.05 12 16.7 0.001 1.9 0.18 0.3 0.64
* Deviation contrast with remainder of cycle.
y
Polynomial linear contrast.
106 Journal of Voice, Vol. 23, No. 1, 2009

TABLE 6.
Correlation Between Mood and Voice Quality on Days 1, 4, 14, and 23 in Female Singers
Day 1 Day 4 Day 14 Day 23
Peak form 0.45 (0.04) 0.28 (0.22) 0.43 (0.05) 0.20 (0.41)
Fatigued voice 0.41 (0.07) 0.28 (0.21) 0.53 (0.01) 0.47 (0.04)
Effort 0.27 (0.24) 0.51 (0.02) 0.42 (0.06) 0.29 (0.22)
Support 0.50 (0.02) 0.24 (0.29) 0.37 (0.10) 0.14 (0.55)
Hoarse 0.45 (0.04) 0.39 (0.08) 0.49 (0.02) 0.37 (0.11)
Weak 0.47 (0.03) 0.29 (0.21) 0.51 (0.02) 0.32 (0.16)
Range 0.33 (0.14) 0.34 (0.14) 0.33 (0.15) 0.24 (0.31)
Control 0.49 (0.03) 0.48 (0.03) 0.50 (0.02) 0.33 (0.16)
Sluggish 0.67 (0.001) 0.40 (0.07) 0.49 (0.03) 0.23 (0.33)
Pitch 0.58 (0.01) 0.20 (0.38) 0.66 (0.001) 0.19 (0.41)
Notes: Pearson’s r value is shown with P value in brackets.

The effects of the cycle were assessed in a number of ways.
We were interested in the variations over the first 7 days of the
cycle, assessed from the first day of bleeding. A second set of
analyses comparing two phases of the cycle were also under-
taken. The cycle was divided into the premenstrual phase and
menstrual phase (days 24–4) when symptoms tend to be at their
maximum and these days were compared to the remainder of
the cycle (days 5–23). Results showed that those taking the
oral contraceptive pill rated their voice quality higher than those
not taking the pill, better their self-reported mood was than
those not on the pill. This supports the research by Ledger
and Davidson (in Comins24) that the contraceptive pill has a sta-
bilizing effect on the voice and may benefit female singers. The
association of better mood with contraceptive pill use needs fur-
ther exploration.
Singers who were not taking a contraceptive pill tended to
rate lower on all voice quality scores, except peak form, a find-
ing that supports Sataloff’s25 assertion that hormone imbal-
ances affect the voice and hormone therapies restore the
voice. Similarly, Amir et al5,26 demonstrated that use of
a low-dose monophasic contraceptive pill was associated with
voice stability through reductions in the extent of hormonal
fluctuations over the cycle.
We were surprised that of the six singers reporting the most
severe menstrual symptoms, two were taking the oral contra-
ceptive pill. Singers were not asked for the specific type of
oral contraceptive pill, although monophasic pills are more
common in Australia than biphasic or triphasic pills. Future re-
search could explore which oral contraceptive pill is most effi-
cacious in reducing symptoms associated with voice-quality
variations in female singers.
After adjusting for the influence of the contraceptive pill, we
also demonstrated that voice was lower and mood was worse in
cycle days 24–4 than in cycle days 5–23 with significant differ-
ences for fatigued voice. Abramson et al (in Emerich et al27)
state that altered metabolic activity by estrogen sensitive cells
could have an effect on the quality of the voice, because vocal
fold hormonal receptor sites are sensitive to estrogen, proges-
terone, and thyroid hormone. More recently, these hormone re-
ceptors have been found in the human vocal folds.28,29 This
finding should lead to more defined clinical reasons for the var-
iations of the singing voice over the menstrual cycle. Through

FIGURE 5. Pedagogue scores for each student. FIGURE 6. Self-rated scores for each singer.
Maree Ryan and Dianna T. Kenny Does Menstrual Cycle Affect Female Classical Singers’ Voices?
the various physiological feedback pathways and the neuro-
endocrine system, mood and body states of the singer will influ-
ence the level of hormone production, in turn triggering the
receptor sites in the vocal folds.
Although male singers were included in the study as a control
group to ascertain to what extent mood and vocal quality fluctu-
ated from day to day without the influence of the female hor-
mones, we were surprised to observe the degree to which the
male singers fluctuated over the 28 days of their diary record-
ings. These fluctuations were less pronounced than for the fe-
males and showed no recognizable points of reference
(‘‘fixed’’ days) to calendar days. The perceived effects of
mood, effort, and physical symptoms were similar in both sexes.
Other recent research has also shown that males display varia-
tion over time in their mood and well-being. Earlier research
by McFarlane and Williams (in Worsey and Aubeeluck30) dem-
onstrated that men may experience cyclical changes, whereas
a more recent study by Worsey and Aubeeluck30 showed that
men and women who completed the Menstrual Distress Ques-
tionnaire (MDQ—Moos, 1968) both complained of symptoms.
Men in fact rated significantly higher on the MDQ than women
for pain, concentration, behavioral change, arousal, and control.
The results indicated that men experience many of the symp-
toms usually associated with menstrual distress in women but
may describe them differently. The preliminary findings obvi-
ously have health inferences for women stereotyped as mani-
festing PMS and also for men with cyclical changes that may
be unrecognized and may require treatment.
Although some cyclical variation was observed in both sexes,
the results for the male singers showed more random fluctua-
tions than those observed in females. There was a trend for
the voice-quality parameters to improve over the first 7 days
of the cycle for both males and females, showing a similar pat-
tern of improvement; however, the male pattern commenced on
a random day 1, as opposed to the physiological day 1 in the fe-
male cycle. This finding suggests that recording symptoms in
a diary format heightens awareness of the observer to their
voice quality, perhaps leading to initially more negative ratings.
However, we have no adequate explanation for this finding and
further research is needed to clarify possible explanations for its
occurrence.
The young women in our study consistently rated their voice
quality lower than the men. Men did not rate their voices differ-
ently across the two cycle phases except for peak form and fa-
tigued voice, whereas the females rated nearly all recorded
symptoms differently between the two cycle phases. Males
scored higher than females for all qualities except range.
Male singers rated peak form significantly higher than female
singers, but there was only a marginal difference between
men and women in ratings of weak voice and sluggish voice.
Over the cycle, fatigued voice improved significantly in both
males and females but the women also had improved ratings
for effort, support, control, and sluggishness, and to a lesser ex-
tent peak form, whereas male ratings showed no differences in
these parameters.
Mood had a stronger effect on the voice than the contracep-
tive pill, an interesting and somewhat unexpected finding.
107
Mood improved somewhat in both males and females over
days 1–7 although the trend was not statistically significant.
The overall mood score was not significantly different between
males and females, although males consistently rated their
mood as better than females. Wicklund8 concluded that ‘‘the se-
verity of PMS symptoms and menstrual dysphonia symptoms
may be linked, implying a similar wide range of mood and
voice quality scores.’’ Abitbol et al7 defined vocal PMS that in-
cluded vocal fatigue, decreased range, loss of vocal power, and
loss of certain high harmonics (huskier voice), with the symp-
toms more pronounced in the premenstrual phase.
In females, most ratings tended to be lower on days 1–3 than
for the remainder of the cycle and there was a trend for some
ratings to rise through days 1–7. Poor mood was directly asso-
ciated with perceived reduced voice quality for all days
throughout the cycle and was significantly greater on days 1
and 14. Similarly, there was a negative association between fa-
tigue and mood at day 14, the peak in hormone secretion around
ovulation. The effect of the menses, that is, withdrawal of hor-
mones, is well documented. Lacina (in Chae et al6) reported that
many female singers had difficulty with intricate phonation
control before each menstruation. Lacina6 also reported that
the changes to the voice appear proportional to the presenting
severity of the premenstrual symptoms, with which this re-
search is in agreement. On the other hand, the midcycle peak
of hormones also apparently affects the voice detrimentally in
association with body and mood states.
Results supported the hypothesis that the voice is affected by
the menstrual cycle and its inherent physiological changes.
However, the effects were not uniform across all singers, a find-
ing also observed by Brown and Rothman,22 who used trained
singers, some of whom were taking the contraceptive pill and
singing tasks such as chromatic scales and phrases where the
voices revealed the most difficulty in phonation.
There was wide variation in ratings of mood and voice qual-
ity across the same days for the two cycles rated by the female
participants. Mood varied more obviously than voice quality,
with worse moods associated with greater variation in vocal
quality.
Five of the six singers who were selected on the basis of
having the worst self-reported vocal symptoms during menstru-
ation correctly identified their performance during menstrua-
tion when presented blind with both their recordings (one on
the first day of menstruation and one at approximately mid-
cycle). Analysis of their diary data also showed that there was
wide variation during both menstruating and nonmenstruating
phases, but with no consistent changes observed. Although
singers were able to identify perceptually their singing samples
taken at different times in their cycles, expert pedagogues did
not reliably discern differences in vocal quality. However,
singers’ awareness of vocal distress and low mood is not neces-
sarily transmitted to their audience. The expert listeners were
unable to reliably discern differences in vocal quality between
the two samples and did not rate the non-menstrual sample con-
sistently higher than the menstrual sample. Recent commen-
tary31,32 has highlighted how singers develop the ability to
discern very subtle differences in vocal quality that listeners
108
cannot. Consequently, singers’ education should include infor-
mation that their perceptions regarding their vocal quality may
not adversely affect perceptual quality.
Future research could replicate this study with the addition of
blood samples assessing hormonal levels over the menstrual cy-
cle, in an attempt to account for the wide variation in vocal and
mood ratings between singers and within singers across two rat-
ing periods.
CONCLUSION
This longitudinal study is important to the singing community,
as it is a methodologically sound study using technically chal-
lenging musical tasks to examine the perceived effects on the
female classical singing voice over the menstrual cycle.
Results indicated that the female hormonal cycle had a per-
ceptual effect on the voice of the young female western classical
singer for the singers who reported being affected by menstrual
symptoms but no discernible perceptual effects on expert lis-
teners. Not everyone reported symptoms and there was wide
variation in symptomatology. However, the results indicated
that a small proportion of singers were severely affected during
the menstrual phase of their cycles. These singers found the de-
mands of coordinating their body more challenging, vocaliza-
tion more effortful, and singing less aurally and artistically
rewarding.
The study demonstrated that self-awareness of the artist is
much more sensitive and critical than the perception of a highly
trained observer, implying that audience satisfaction is not nec-
essarily as difficult to achieve as self-satisfaction.
Acknowledgments
We thank Dr Peter Lorenz, MBBS FRACGP DObstRCOG, for
expert advice on the medical components of the study and for
support with the preparation of the manuscript.
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