Original Paper
Folia Phoniatr Logop 2013;65:7883
DOI: 10.1159/000350405
Comparison of Speaking Fundamental
Frequency between Premenopausal Women
and Postmenopausal Women with and
withoutHormone Therapy
EvelienDhaeseleer a HermanDepypere b KristianeVanLierde b
a
Department of Otorhinolaryngology and Logopaedic and Audiologic Sciences, and
b
Department of Gynaecology, Ghent University, Gent, Belgium
Key Words
Menopause Hormone therapy Adipose tissue Body mass
index Voice Speaking fundamental frequency
Abstract
Objective: The purpose of this study was to investigate the
speaking fundamental frequency (SFF) in pre- and post-
menopausal women with and without hormone therapy
(HT) and with low and high body mass index (BMI). Patients
and Methods: The SFF of premenopausal women with low
BMI (n = 22) was compared with the SFF of premenopausal
women with high BMI (n = 13), postmenopausal women
with HT and low BMI (n = 35), postmenopausal women with
HT and high BMI (n = 19), postmenopausal women without
HT and with low BMI (n = 28) and postmenopausal women
without HT and with high BMI (n = 12) using ANCOVA and
post hoc tests. Results: A significantly lower SFF of the voice
was only found in postmenopausal women without HT and
with a low BMI. Conclusion: The results of this study sug-
gest that the menopause lowers the voice with approxi-
mately 14 Hz and that HT and adipose tissue (high BMI)
might counteract the menopausal drop in SFF.
Copyright 2013 S. Karger AG, Basel
2013 S. Karger AG, Basel
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Published online: August 14, 2013
Introduction
The voices of middle-aged women are subject to a
combination of aging and menopausal transition. The
menopause ends the reproductive period and is charac-
terized by a decrease in the female sex hormones estrogen
and progesterone. The hormone balance and the ratio of
estrogen and progesterone to androgens changes and the
influence of androgens becomes more important in the
female body. In the postmenopausal period, ovarian con-
tribution of estrogen is negligible, and adipose tissue be-
comes the main source of estrogen production [1].
The menopausal transition has been associated with
several changes in voice characteristics like a decrease in
fundamental frequency (F0) [25], a reduction in fre-
quency range and intensity (sound pressure level) range
[3, 5] of the voice and an increase in F0 variability [6].
However, in most of the studies, the influencing variable
aging was not taken into account. When controlling for
the effect of the general aging process, the most typical
vocal change after menopause is a decrease in the speak-
ing fundamental frequency (SFF) [7].
Hormone therapy (HT) has a long-standing tradition
for the treatment of menopausal complaints. It compen-
sates for the drop in endogenous estrogen and or proges-
Evelien Dhaeseleer
Department of Otorhinolaryngology and Logopaedic and Audiologic Sciences
Ghent University, De Pintelaan 185, 2P1
BE9000 Gent (Belgium)
E-Mail Evelien.Dhaeseleer@Ugent.be
terone levels in the postmenopause. HT usually consists
of a combination of estrogens and progestogen because
of the increased risk of endometrial hyperplasia [8]. In
hysterectomized women HT can consist of estrogens
alone. HT also affects the voice [2, 3, 9]. Lindholm et al.
[2] investigated the effect of two types of HT on the acous-
tic characteristics of the voice in postmenopausal women
(n= 32). After 1 year, the SFF decreased significantly in
the group without HT. In the groups with HT, the mean
SFF decreased in spontaneous speech but the decrease
was smaller than that in the group without HT. After
menopause, a decrease in SFF occurs, and HT counteracts
these voice changes in postmenopausal women.
In postmenopausal women adipose tissue becomes the
main source of estrogen production. In fat cells, andro-
gens are converted into estrones by aromatase. Cyto-
chrome P-450 is responsible for this biosynthesis, and the
gene involved is Cyp19 [1]. As the fat cell mass increases,
the level of endogenous estrogens also increases. Logical-
ly, obese women have a higher production of estrone and
higher estrone levels than do normal-weight women [10,
11]. Dhaeseleer et al. [12] showed that the body mass in-
dex (BMI) of postmenopausal women without HT is pos-
itively correlated with the SFF. This means that postmeno-
pausal women without HT with a higher BMI tend to have
a higher SFF. In studies about the impact of menopause
on SFF of the voice the BMI should be taken into account.
Regarding the SFF in middle-aged women a distinc-
tion should be made between premenopausal women,
postmenopausal with HT and postmenopausal women
without HT. In the literature [12] a positive correlation
between SFF and BMI was shown in postmenopausal
women without HT. In a study with young premenopaus-
al women, Gonzlez [13] found no relation between BMI
and vocal characteristics. Therefore, in this study a sec-
ond distinction in each group between high and low BMI
is necessary. To the best of our knowledge, no studies in-
vestigating the interaction between menopause, HT and
BMI on voice characteristics have been reported.
The purpose of this study was to investigate the SFF in
premenopausal women, postmenopausal women with
HT and postmenopausal women without HT, with high
and low BMI.
Methods
Subjects
Patients visiting the Department of Gynecology for a routine
consultation were asked to participate to the study. Patients were
included in the study only after signing an informed consent state-
Comparison of SFF between Pre- and
Postmenopausal Women
ment. This study was approved by the human subject committee
of the University of Ghent (04017).
One hundred and twenty-nine middle-aged women participat-
ed in the study. Each subject was assessed by the same gynecolo-
gist(H.D.) to confirm the menopausal status. Inclusion criteria for
premenopausal women were regular menstrual cycle (premeno-
pause) and minimum age of 45 years. The premenopause is the
reproductive period before perimenopause and the menopause.
Bydefinition, women with regular menstrual cycles have an opti-
mal balance of follicle-stimulating hormone, luteinizing hor-
mone,progesterone, and estrogen levels to provide a regular pro-
liferation and desquamation of the endometrium. For menopause
a clinical examination in combination with a cervical smear was
used to confirm the menopausal status. Since natural menopause
is clinically defined as the final menstrual period, 12 consecutive
months of amenorrhea were required [14]. In case of an ovariec-
tomy there was a surgically induced menopause. Perimenopausal
women with menopausal complaints or irregular menstrual cycles
were excluded from the study.
The subjects were divided into six groups: premenopausal
women with low BMI, premenopausal women with high BMI,
postmenopausal women with HT and low BMI, postmenopausal
women with HT and high BMI, postmenopausal women without
HT and with low BMI and postmenopausal women without HT
and with high BMI.
For the BMI classification a cutting point of 25 was used [15].
Women with a BMI lower than 25 (corresponding to normal
weight or underweight [15]) were included in the group with low
BMI. Women with a BMI higher than 25 (overweight [15]) were
included in the group with high BMI.
Mean age, BMI and time of menopause of the six groups are
presented in table 1. In the group of premenopausal women 12
patients used oral contraceptive pills. There is no impact of oral
contraceptive pills on the variable measured in this study (SFF) in
premenopausal women (independent sample t test, p = 0.227). In
the group of postmenopausal women with HT, 11 women received
estrogen therapy. The other 43 women received a combination of
estrogens and progestogen. There were no differences in SFF be-
tween the two types of hormones (independent sample t test, p =
0.506).
An examination of ear, nose and throat was performed by an
otorhinolaryngologist to exclude organic voice disorders. Smokers
and subjects with a cold were excluded from the study. None of
thewomen had a history of endocrine diseases or organic pathol-
ogy. Videostroboscopy revealed a normal structure and function
of the vocal folds in each subject. All subjects were in good physical
and mental state of well-being and had normal hearing (pure-tone
average less than 20 dB in the poorer ear). The maximum age for
inclusion was 70 years. Other influencing variables (vocal abuse,
stress, allergy and reflux) in subjects are presented in table2. None
of these variables were significantly different between the six
groups (2 test, = 0.05).
Voice Assessment
The mean SFF of connected speech was measured using Real-
Time Pitch (model 5121 V3.1.6) program from Computerized
Speech Lab from Kay. Real-Time Pitch of Computerized Speech
Lab is an accurate F0 extractor for normal and pathological voic-
esin both sustained voicing and running speech [16]. It extracts
F0 very quickly on a cycle-to-cycle basis (manual Computerized
Folia Phoniatr Logop 2013;65:7883 79
DOI: 10.1159/000350405
Table 1. Characteristics of the pre- and postmenopausal women with and without HT with low and high BMI

n Age, years BMI Time of menopause, years

mean SD mean SD mean SD
Premenopausal women low BMI 22 48.5 2.3 21.6 1.9
Premenopausal women high BMI 13 48.1 2.3 29.0 4.4
Postmenopausal women with HT low BMI 35 57.5 5.0 22.4 1.9 7.6 4.5
Postmenopausal women with HT high BMI 19 56.7 4.1 27.3 1.8 7.1 3.5
Postmenopausal women without HT low BMI 28 58.5 5.5 22.5 1.7 8.2 6.6
Postmenopausal women without HT high BMI 12 59.4 5.4 28.0 2.2 11.2 5.4

Table 2. Influencing variables in pre- and postmenopausal women

Premenopausal Postmenopausal with HT Postmenopausal without HT 2

low BMI high BMI low BMI high BMI low BMI high BMI p value
n (%) n (%) n (%) n (%) n (%) n (%)
Vocal abuse 1 (5) 0 (0) 0 (0) 0 (0%) 1 (4) 0 (0) 0.705
Stress 7 (32) 7 (54) 15 (43) 8 (42%) 12 (43) 2 (17) 0.619
Allergy 8 (36) 4 (31) 7 (20) 7 (37%) 8 (29) 4 (33) 0.911
Reflux 5 (23) 2 (15) 4 (11) 5 (26%) 2 (7) 3 (25) 0.673

Table 3. Comparison of the SFF in premenopausal women, post- manual of the Computerized Speech Lab. The participants were
menopausal women with HT, postmenopausal women without instructed to read a text (Dutch version of The North Wind
HT and with high BMI and postmenopausal women without HT andthe Sun) once at a habitual pitch and loudness. All voice as-
and with low BMI sessments were always performed by the same voice therapist
(E.D.).Test-retest reliability of running speech Real-Time Pitch
n SFF, Hz ANCOVA is very high with a Pearsons correlation coefficient of 0.94, p <
mean SD p value 0.00001 [16].
Premenopausal women Statistical Analysis
low BMI 22 188.3 17.6 SPSS version 17 (SPSS Corp., Chicago, Ill., USA) was used for
Premenopausal women
the statistical analysis of the voice data. For the comparison of
high BMI 13 189.6 15.1
Postmenopausal women SFF between premenopausal women, postmenopausal women
with HT low BMI 35 188.7 18.2 with HT, postmenopausal women without HT and low BMI and
Postmenopausal women postmenopausal women without HT and high BMI an ANCOVA
with HT high BMI 19 187.8 22.6 (with age as a covariance) was performed. For further analysis be-
Postmenopausal women tween the premenopausal group with low BMI on the one side and
without HT low BMI 28 174.5 17.8 the premenopausal group with high BMI, the postmenopausal
Postmenopausal women groups without HT, with HT and high BMI and with HT and low
without HT high BMI 12 183.0 11.3 0.016 BMI (six planned comparisons) the LSD test was used. Signifi-
cance level for each test was set at p = 0.05.

Speech Lab). To provide accurate F0 extractions the following set- Results

tings were applied to control influencing factors, as recommend-
ed in the manual. A sampling rate of 50,000 Hz was used. To
minimize acoustic reflection, measurements took place in a
sound-treated room in the Ghent University Hospital in Belgium.
The microphone was placed close to the mouth using a head set
to minimize the impact of the relative amplitude of acoustical re-
flections and competing acoustical signals as suggested in the
The results of the SFF in pre- and postmenopausal
women with and without HT and with low and high BMI
are presented in table3. The six groups of women show
asignificantly different mean SFF (ANCOVA, p = 0.016,
F = 2.907, d.f. = 5).

80 Folia Phoniatr Logop 2013;65:7883 Dhaeseleer/Depypere/VanLierde

DOI: 10.1159/000350405
 Table 4. Planned comparisons between premenopausal group with low BMI and the other groups
Premenopausal women low BMI
The results of the planned comparisons between the
premenopausal group with low BMI and the five other
groups using the post hoc LSD test are presented in ta-
ble4. Only the SFF of the group of menopausal women
without HT and low BMI was significantly lower com-
pared to the premenopausal group with low BMI (p =
0.010).
Discussion
The purpose of this study was to investigate the SFF in
pre- and postmenopausal women with and without HT
and with low and high BMI. One of the major difficulties
in this research is the distinction between effects of the
aging process and those of the menopause. In many stud-
ies [46], a large age gap exists between postmenopausal
women and younger premenopausal women. To investi-
gate menopausal symptoms and distinguish between the
effects of aging and those of menopause, the World
Health Organization [17] recommended a cross-section-
al study design including large numbers of middle-aged
women within a restricted age range in order to distin-
guish the differences in symptom frequency by meno-
pausal status, while controlling for age [17]. Therefore, in
this study the inclusion criterion for premenopausal
women was a minimum age of 45 years in order to mini-
mize the age gap between pre- and postmenopausal
women. Secondly, in the statistical analysis the variable
age was included as a covariant. Furthermore, the effect
of HT and BMI on the voice should be taken into account.
To the best of our knowledge no studies regarding the
voice have investigated the interaction between meno-
pause, HT and BMI.
The SFF of premenopausal women with low BMI was
compared with the SFF of premenopausal women with
high BMI, postmenopausal women with HT and low
BMI, postmenopausal women with HT and high BMI,
Comparison of SFF between Pre- and
Postmenopausal Women
LSD
p value
Premenopausal women high BMI 0.837
Postmenopausal women with HT low BMI 0.934
Postmenopausal women with HT high BMI 0.937
Postmenopausal women without HT high BMI 0.010
Postmenopausal women without HT low BMI 0.428
postmenopausal women without HT and with low BMI
and postmenopausal women without HT and with high
BMI. The results of this study show that the SFF of pre-
menopausal women with low BMI (mean: 188.3 Hz)
only differed from the SFF of postmenopausal women
without HT and with low BMI (mean: 174.5 Hz). The
mean difference in SFF between these two groups was
14 Hz. This difference of 14 Hz corresponds to 1.32
semitones or to 7.6% [(188.8174.5 Hz)/188.8 Hz]. An
interesting question is whether these rather small differ-
ences are perceptually relevant or detectable for listen-
ers. For pure tones between 100 and 2,000 Hz the just
noticeable difference also known as frequency difference
limen is 3 Hz [18, 19]. However, the voice is a complex
acoustic signal. According to Moore and Moore [20] F0
differences (of complex tones) of more than 1% are de-
tectable for listeners. Thus, in general the menopausal
changes in F0 must be detectable for listeners. However,
listeners differ in their ability to detect F0 changes [21].
The drop in F0 is a gradual process within the general
aging process. Therefore, it is possible that not all post-
menopausal women without HT and low BMI will detect
the changes in the SFF of their voice. Furthermore, pre-
vious studies [7, 22] have shown no relation between
postmenopausal vocal changes and vocal complaints or
psychosocial functioning.
The drop in SFF in thin postmenopausal women
without HT can hypothetically be explained by the estro-
gen deficiency after menopause. In the literature estro-
gen deficiency has been associated with edema [3] and
mucosal atrophy and dystrophy [3, 23]. According to
Abitbol et al. [3] each sex hormone has its own direct
impact on the larynx and the vocal folds. Estrogens have
a hypertrophic and proliferative effect on the mucosa.
They reduce the desquamating effect of the superficial
layers and cause differentiation and maturation of fat
cells. Estrogens increase capillary permeability and the
secretions of the glandular cells above and under the vo-
Folia Phoniatr Logop 2013;65:7883 81
DOI: 10.1159/000350405
cal free edge but have no effect on striated muscles [3].
Progesterone has an antiproliferative effect and acceler-
ates desquamation. In addition, progesterone causes de-
hydration of the mucosa with a reduction in secretions
of the glandular epithelium. It decreases and even inhib-
its capillary permeability which can result in tissue con-
gestion. Androgens cause reduction of the glandular se-
cretions and a loss of hydration and atrophy of the laryn-
geal mucosa [3]. In the skeletal muscles androgens cause
hypertrophy with a reduction in fat cells [3]. When es-
trogen levels decrease, the relative impact of androgens
on the vocal folds increases. However, how these organ-
ic changes in the vocal folds are related to the drop in F0
of the voice is not clear yet.
No differences in SFF were found between premeno-
pausal women and postmenopausal women with HT
with low or high BMI. This could possibly be explained
by the fact that the low estrogen-progesterone levels are
already compensated for by the intake of exogenous hor-
mones. The first reports in the literature about the impact
of HT on the vocal characteristics show that postmeno-
pausal women with HT have a higher SFF compared to
postmenopausal women without HT [2, 9]. The results
ofthis study confirm that HT prevents the menopausal
drop in SFF.
In postmenopausal women without HT the BMI
seems to be an important influencing variable. In previ-
ous research a positive correlation was found between
BMI and SFF [12]. Postmenopausal women (without
HT) with a higher BMI tend to have a higher SFF. In
postmenopausal women adipose tissue becomes the
main source of estrogen production. As the fat cell mass
increases, the level of endogenous estrogens also increas-
es. Women with a higher BMI have a higher production
of estrone and higher estrone levels than normal-weight
women [10, 11]. Logically, no menopausal changes in
SFF were found in postmenopausal women with a high
BMI (and without HT).
Several limitations of this thesis are considered. The
cross-sectional study design to investigate the impact of
menopause and HT on the SFF has its limitations. Mid-
dle-aged women are a very heterogeneous group with a
lot of variables influencing the vocal characteristics like
age, BMI, smoking habits, etc. Most of the influencing
variables are controlled, however some variables (like life
habits, vocal habits, vocal load, vocal hygiene during life-
time, etc.) are difficult to control. A longitudinal study of
the voice on the one hand during pre-, peri- and post-
menopausal stages and on the other hand pre- and post-
HT would exclude more variables. Sample sizes in this
cross-sectional study were rather small. In future studies
with the same design, larger study groups must be includ-
ed. Another shortcoming of this study is the absence of
serum levels of the different sex hormones. In addition,
BMI is not a direct measure of the percentage of body fat.
A measure of endogenous estrogens would provide more
robust conclusions on possible associations. In future
studies serum levels of sex hormones and levels of atro-
phy in cervical smears would provide additional informa-
tion and could be used in a correlation between the levels
of sex hormones and vocal characteristics. Finally, this
study does not provide any insights as to the impact of
changing BMI in middle-aged women. Many women
gain weight at menopause. In the future, a longitudinal
study can investigate the relation between a changing
BMI during menopause and the SFF.
Conclusion
A significantly lower SFF was only found in postmeno-
pausal women without HT and with a low BMI. The re-
sults of this study suggest that the menopause lowers the
voice by approximately 14 Hz and that HT and adipose
tissue (high BMI) might counteract the menopausal drop
in SFF.

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