Hormones, Hypermobility, and Voice: What’s the Link?
WRITTEN BY JOANNE BOZEMAN
Is there a link? Probably. It won't surprise anyone that more research is needed. Nonetheless, there is enough evidence that hormonal contexts including puberty, the menstrual cycle, pregnancy, lactation, and the menopause transition can impact people with symptomatic hypermobility, HSD, and hEDS/EDS. Furthermore, research that looks at the voice in these contexts has so far gotten scant attention. Complicating matters is that connective tissue disorders are on a spectrum, ranging from minor complaints to the various iterations of Ehlers-Danlos Syndrome, of which hypermobile-type EDS (hEDS) is by far the most common. It's important to add that experiences with these conditions vary, including individual reactions to hormonal variations.
Regardless, we can consider studies, clinical and anecdotal information that may be helpful for singers with hypermobile conditions. Affected joints may include the tiny ones of the larynx as well as connective tissues involved in phonation, that is, the tissues of the vocal folds, structures that support the larynx, and the respiratory system. We will return to that later.
About Hormones (the Sex Steroid/"Reproductive" Ones)
For male/XY* bodies, testosterone likely has little effect on collagen, and its positive influence on muscle mass likely increases joint stability. Testosterone levels are relatively stable over the month, though they gradually decline over the lifetime.
For female/XX* bodies, or any person that menstruates, the hormonal reproductive cycle and the menopause transition cause fluctuating hormonal levels. The main ones, the sex steroid hormones - estrogen and progesterone - appear to have effects on collagen, ligaments, muscle strength, and neuromuscular control. Most people are not aware that the hormone, relaxin, which causes joint laxity in pregnancy, is actually present in the follicular (pre-ovulation) and luteal (post-ovulation) phases of the cycle. And during lactation (breastfeeding), prolactin levels are high, also increasing joint laxity.
Regarding which parts of the menstrual cycle are apt to cause more symptoms for hypermobile people, the jury appears to be out. Some research reports that in the ovulatory phase, when estrogen is at its peak, ligaments are looser, with an associated increase in athletic injury, but it's it's important to say that this study did not specify the presence of hypermobility in its participants. Other sources and experts lay the blame on progesterone, which is at its highest level in the luteal phase, that is, the five days or so before menstruation starts, and for the first few days of the period. Some hypermobile women notice aggravated joint pain, strains and even more dislocations or subluxations at this time of the month. If so, consider using support strategies for vulnerable joints during this phase of the cycle.
Other Hormonal Influences
Hormone-based birth control methods may have effects on hypermobile symptoms, particularly those that are based on progestins (synthetic progesterone-like hormones). These include progestin-only birth control methods, including pills, injections, pellets that remain under the skin, and even progesterone-releasing IUDs. If a worsening of symptoms (for singers, this might include voice changes) is noticed, experts suggest exploring other birth control methods, or consider other oral contraceptives**, such as an estrogenic hormone only, or one that combines an estrogen and a progestin. Based on clinical experience, one source notes that birth control pills that contain drospirenone, including Yasmin™ and similar formulations, may cause particular joint symptoms in some users.
The menopause transition, typically beginning in the early 40s and lasting ca. 4-10 years, features irregular cycles and fluctuating and lowering estrogen and progesterone levels. A large percentage of non-hypermobile women report muscle and joint pain during this phase of life. It follows that those with hypermobile conditions may have an increase in their symptoms and studies bear this out. Menopause hormone therapy (MHT) with estrogen may offer support for these discomforts as well as other menopausal symptoms, which may include related voice changes, but experiences vary. Worthwhile approaches include extra self-care, mindfulness and gentle exercise, according to one expert in the field.
What About Effects on the Singing Voice?
As to how the hormones-plus-hypermobility scenario may impact the singing voice, we lack specific research. Anecdotal reports exist, and it would be fair to say that just as hypermobility is on a spectrum and affects people in various ways, it's likely the same when you add singing to the mix. As noted above, changes in hormone levels affect several things: joint laxity, coordination, and neuromuscular control, and hypermobile bodies may be particularly affected when hormone changes occur, especially in athletic contexts. So, it's reasonable to project that singers, who have exquisite sensitivity to miniscule voice-related joints, coordination and neuromuscular control, may notice related alterations and/or difficulties in singing.
Suggestions for Singers
For those who have a menstrual cycle, consider keeping a regular symptom journal (easy to do with a calendar or dedicated app) along with tracking your cycle, and include voice behavior changes. This will give you the opportunity to do a personalized "case study"! Perhaps you notice that singing is easier and more stable at certain times of the month - or perhaps you notice that the voice is less predictable and your joints feel less stable as you approach your period. Correlating your voice and other symptoms along with hormonal conditions can lead to greater self-awareness, sensible adjustments in vocal demands and developing helpful strategies. When your voice is feeling more fragile or unstable, you can, perhaps emphasize song choices to more mid-range and delay singing those that require full-on "power". Mark - that is, if comfortable, sing more softly, take notes down the octave, etc. - in rehearsals. Perhaps ask your voice teacher or coach to schedule a lesson about 3-4 days before your period to work on strategies to avoid over-taxing your voice and to help you avoid unhelpful compensations. If you are negotiating the menopause transition (peri- to post-menopause) then it's also a great idea to have an understanding and informed teacher at your side. In lessons, practice sessions and rehearsals, find a position that is most comfortable and stable - sitting, perching on a bar stool or a set piece. You know your body and voice better than anyone. Setting sensible - literally! - priorities will pay off in the long run as you live and sing through the hormonal seasons of life.
*Discussing hormonal differences in terms of binary sex is admittedly over-simplified. We acknowledge that differences in sex development (DDS, including intersex people) and the use of hormone therapies by transgender individuals complicates these scenarios. More related research is needed for non-binary populations.
**For singers who wish to preserve their accustomed singing qualities, the use of hormone-related medications is best considered with cross-consultation with your voice care doctor and your medication prescriber.
Sources Consulted
(Most of these include links to related studies.)
https://www.edhs.info/heds-and-hsd-hormones-and-hypermobility
https://www.hypermobility.org/hormones-and-hypermobility
https://www.hypermobilitymd.com/post/hype-hormones-and-hypermobilty
https://jeanniedibon.com/navigating-menopause-with-hypermobility-and-ehlers-danlos-syndrome/
