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ORIGINAL PAPERS
Adv Clin Exp Med 2009, 18, 3, 291–295
ISSN 1230−025X
© Copyright by Wroclaw Medical University
MARIA ZALESSKA−KRĘCICKA1, ZYGMUNT ZDROJEWICZ2, ALEKSANDRA SKRZYPEK1,
MONIKA MORAWSKA−KOCHMAN1, MARTA MATUSIAK−KITA3, MARCIN JUST4,
KATARZYNA OSTASIEWICZ4, KAROLINA BYNDAS5, TOMASZ KRĘCICKI1
The Influence of Hormonal Oral Contraception
on Voice Parameters in Young Women – a Pilot Study
Wpływ doustnej antykoncepcji hormonalnej na parametry głosu
młodych kobiet – doniesienie wstępne
1
ENT Head and Neck Surgery Department, Wroclaw Medical University, Poland
Endocrinology, Diabetology, and Isotopic Treatment Department, Wroclaw Medical University, Poland
3
1st Gynecology and Obstetrics Department, Wroclaw Medical University, Poland
4
Wrocław University of Technology, Poland
5
Protective and Special Needs Pedagogic Faculty, Opole University, Poland
2
Abstract
Objectives. Evaluation of the influence of modern hormonal contraceptive preparations on voice and acoustic
voice analysis parameters in young women.
Material and Methods. Twenty−nine women were examined (mean age: 25, range: 21–37 years). All patients used
hormonal contraceptive pills available on the Polish market. ENT examination and endoscopic evaluation of the
larynx were performed. Videostroboscopy of the larynx was performed in each patient, then voice samples were
recorded using a dynamic microphone with a preamplifier connected to the sound card of a PC in a room with
a noise level no higher than 30 dB. Each sample was acoustically analyzed using Iris software for MDVP.
Conclusions. There were no statistically significant changes in the Jitter and Shimmer parameters in the women
who used oral hormonal contraception. Statistically significant changes in higher formant frequencies of the vowel
“a” were observed. The use of hormonal contraception influenced subjective voice evaluation in the investigated
women only to a small degree. The use of hormonal contraception could result in the retention of thick mucus in
the larynx (Adv Clin Exp Med 2009, 18, 3, 291–295).
Key words: oral hormonal contraception, voice analysis parameters, voice, contraceptive pills, contraception.
Streszczenie
Cel pracy. Ocena wpływu nowoczesnych hormonalnych doustnych preparatów antykoncepcyjnych na głos i para−
metry analizy akustycznej młodych kobiet stosujących takie preparaty.
Materiał i metody. Zbadano 29 kobiet (średnia wieku 25 lat, zakres 21–37). Wszystkie pacjentki stosowały
preparaty antykoncepcyjne dostępne na polskim rynku. U każdej badanej wykonano badanie laryngologiczne
i endoskopowe krtani. Na pierwszym etapie wykonano badania wideostroboskopowe krtani, a następnie z użyciem
mikrofonu dynamicznego połączonego z kartą dźwiękową komputera PC nagrywano próbkę głosu. Poziom hałasu
w pomieszczeniu, w którym dokonywano nagrań, nie przekraczał 30 dB. Każdą próbkę głosu poddawano analizie
akustycznej za pomocą programu Iris do MDVP.
Wnioski. Nie stwierdzono istotnych statystycznie różnic w parametrach Jitter Shimmer u kobiet stosujących
doustną antykoncepcję hormonalną. Zaobserwowano istotne statystycznie zmiany częstotliwości wyższych for−
mantów głoski „a”. Stosowanie doustnej antykoncepcji hormonalnej tylko w niewielkim stopniu wpływa na
subiektywną ocenę głosu u badanych kobiet. Stosowanie doustnej antykoncepcji hormonalnej może wiązać się
z zaleganiem gęstej treści śluzowej w krtani (Adv Clin Exp Med 2009, 18, 3, 291–295).
Słowa kluczowe: doustna antykoncepcja hormonalna, parametry analizy głosu, głos, tabletki antykoncepcyjne,
antykoncepcja.
* The study was financed by grant no. 1471 of Wroclaw Medical University.
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M. ZALESSKA−KRĘCICKA et al.
There is a close relationship between voice
emission and endocrine gland function. Birds and
mammals in estrus use voice to express their affec−
tive condition and entice the other sex. The influ−
ence of sex hormones on the voice organ in
humans has significant impact, also on thus the
biological mechanism of species preservation. The
voice organ, especially in women, is subject to the
influence of hormones throughout life. Dysphonia
premenstrualis, or premenstrual vocal syndrome
(PVS), caused by a reduction of blood estrogen
level in the post−ovulatory phase of the menstrual
cycle [1–3], constitutes an example. So−called
androphonia, a disorder of voice in women, is
often caused by exogenous factors such as the
application of sex hormone−containing medica−
tions [4, 5]. Estrogen and androgen−estrogen
preparations have particular importance in the
treatment of menstrual disorders and as a method
of contraception. In some cases, anti−androgen−
active substances are also used. During the post−
menopausal period, some changes in the voice
organ take place which are related to the depletion
of ovarian function. Masculinization of the larynx
occurs and the voice lowers and becomes easily
exhausted and weaker [4].
The aim of the study was an evaluation of the
influence of modern contraceptive preparations on
voice and acoustic voice analysis parameters in
young women using oral hormonal contraception.
The results of this study could be especially
important for individuals working professionally
with voice, as early studies investigating the influ−
ence of hormonal contraception on voice (large
doses of hormones) discouraged women from this
method of family planning.
Material and Methods
Twenty−nine women were examined (mean
age: 25, range: 21–37 years). All the patients used
hormonal contraceptive pills available on the
Polish market (Cilest: 0.035 mg ethynylestradiol
+ 0.25 mg norgestymat, Logest: 0.2 mg ethyny−
lestradiol + 0.075 gestagen, Diane: 35–0.035 mg
ethynylestradiol + 0.002 mg cyproterone acetate).
The average period of pill use was 37 months.
ENT examination and endoscopic evaluation of
the larynx were performed. During the first stage
of the study, videostroboscopy of the larynx was
performed in each patient, then voice samples
were recorded (a phonetically balanced sentence
in Polish and the vowel “a”) using a dynamic
microphone with a preamplifier connected to the
sound card of a PC in a room with a noise level no
higher than 30 dB. Each sample acoustically ana−
lyzed using Iris software for the Multi−
Dimensional Voice Program (MDVP). The sam−
ples of the vowel “a” and the phrase: „Dzisiaj jest
ładna pogoda” [’daj ‘jest ‘wadna po’goda] (“It
is a beautiful day”) were analyzed separately.
Basic parametric analysis, formant analysis,
voice field, harmonic analysis, and spectrographic
analysis were performed. Each patient filled out
a questionnaire regarding general health and
endocrinal and ENT disorders. A control group
was examined analogously. This group consisted
of healthy female students of Wrocław universities
with the proper mean and range of age who did not
use hormonal contraceptives. The results of
acoustic voice analysis were statistically analyzed
using Statistica 7.1 software. Mann−Whitney
U tests were conducted. During this study there
were no voice acoustic parameter norms in the lit−
erature for Iris multiparameter acoustic analysis
beside basic frequency of voice. Norms were not
defined. Such analysis is considered a proper tool
for population investigation and comparing groups
in it or to monitor changes in voice over time in the
same patient, for example during therapy. It was
therefore used to examine women using hormonal
contraception and compare the results with those
not using it.
Results
The results of the questionnaire concerning
voice disorders showed that 5 women reported
hoarseness since using hormonal contraceptive
pills and 1 reported voice fatigue. The presence of
dense mucus was observed by videostroboscopy in
90% of the examined women and vocal nodules in
3 women. It is probable that these vocal nodules
were the result of improper voice emission habits
and loss of professional voice training.
Changes in almost all the investigated parame−
ters were found during acoustic voice analysis of
the vowel “a” (Table 1). Only the parameters F0
(basic frequency), F0_Dev (standard deviation of
the basic frequency), and A_Dev (standard devia−
tion of the amplitude) were examined during
acoustic analysis of the sentence (Table 2).
Statistically significant (p < 0.05) or nearly signif−
icant changes appeared in acoustic analysis of the
vowel “a” for the parameters F3_Dev (standard
deviation of the third formant frequency; Mann−
−Whitney U, p = 0.0627) and F4_Dev (standard
deviation of the fourth formant frequency; p =
= 0.0489) (Table 3). A nearly statistically signifi−
cant change appeared in acoustic analysis of the
sentence for F0_Dev (standard deviation of basic
frequency; p = 0.066629) (Table 4).
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Oral Contraception and Voice in Young Women
Table. 1. Acoustic voice analysis of the vowel “a”.
Changes of parameters compared with the control group.
NHR – noise−to−harmonic ratio, U2H – unharmonic−to−
harmonic ratio, YG – continuous Yanagihara factor
Table 3. Statistically significant results of the acoustic
analysis of the vowel “a”
Tabela 3. Istotne statystycznie wyniki analizy statysty−
cznej samogłoski “a”
Table 1. Analiza akustyczna głosu samogłoski „a”.
Voice analysis parameter
(Wskaźnik analizy głosu)
Percent change
(Zmiana %)
F0
–6
F0_Dev
57
Jitter
Mann−Whitney U test
close to p < 0.05
F3_Dev
0.0627
F4_Dev
0.0489
12
Jitter_Dev
25.5
Shimmer
1.5
Shimmer_Dev
Parameter
(Wskaźnik)
–1.5
U2H
18
NHR
25.5
YG
4.5
F1
–10.5
F2
–7.5
F3
0
F4
–1.5
F1_Dev
9
F2_Dev
–16.5
F3_Dev
−57
F4_Dev
–46.5
Table 2. Acoustic analysis of selected parameters of the
sentence: „Dzisiaj jest ładna pogoda”. Changes compared
with controls
Tabela 2. Analiza akustyczna wybranych wskaźników
zdania “Dzisiaj jest ładna pogoda”. Zmiany w porówna−
niu z grupą kontrolną
Parameter
(Wskaźnik)
Percent change
(Zmiana %)
F0
−3
F0_Dev
−16
A_Dev
−1
Discussion
There is a long history of research concerning
the relationship between the human larynx and sex
hormones in women [1, 6, 15, 16]. The female
organism is influenced by two main sex hormones:
estrogen and progesterone. Both influence mainly
the reproductive system [7, 8]. However, their
influence on other tissues and organs, including
the larynx, has been proven [2, 9]. Similarities in
cytological samples of vocal fold epithelium and
cervix epithelium have been found [6]. Estrogen
causes hypertrophy of the laryngeal mucosa and
increases glandular cell secretion in the region of
Table 4. Statistically significant parameter changes in
acoustic analysis of the sentence: „Dzisiaj jest ładna
pogoda”
Tabela 4. Istotne statystycznie zmiany wskaźnika
w analizie akustycznej zdania „Dzisiaj jest ładna pogoda”
Parameter
(Wskaźnik)
Mann−Whitney U test
close to p < 0.05
F0_Dev
0.066629
the vocal folds, which has been shown in
histopathological examinations. The balance
between the two hormones changes during the
course of the menstrual cycle. Progesterone leads
to congestion of the vocal fold tissue and edema−
tous changes of the vocal folds, which is typical of
the perimenstrual period [3]. It also reduces the
amount of glandular secretion, which results in
a greater stringiness and acidity of the mucus and
the sensation of tissue dryness [7]. These reports
have been confirmed by the presence of androgen
and estrogen receptors in the human larynx epithe−
lium found in both intraoperative and cadaver
samples [10]. Progesterone receptors were detect−
ed in cellular nuclei and cytoplasm of laryngeal
epithelial cells. The results of Schneider et al.,
however, contradict this; according to them there
are no characteristics of the expression of sex
steroid receptors in the vocal folds [11].
Female voice changes frequently observed in
clinical practice are related to the life cycle of the
organism, which is subject to the influences of sex
hormones. Dynamic changes in sex hormone levels
determine the basic voice frequency oscillations
during puberty, maturity, and menopause [12].
Significantly higher values of jitter and shimmer
have been found prior to menstruation in studies of
premenstrual syndrome. This especially concerns
women who use their voice professionally, whose
voice changes are not related to emotional excita−
tion or have no psychogenic basis [1, 3, 4, 8]. The
morphological changes taking place in the vocal
folds during the premenopausal phase of life lead
to a reduction of connective tissue and mucosa
flexibility and increased vocal fold mass and thus
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M. ZALESSKA−KRĘCICKA et al.
to a lowering of voice pitch and control. Hormonal
replacement therapy in menopausal women also
affects the voice, moderating changes related to
menopausal hormonal disorders [8, 9, 12, 13]. It is
assumed that changes in sex hormone levels could
affect the neuromotor control of the larynx [13].
Hormonal contraception results in maintaining
specific and constant estrogen and progesterone
levels, thus suppressing ovulation. Therefore it
seems that voice changes will be smaller in
women using oral hormonal contraception than in
those who do not. This has been confirmed by
Amir et al. [2, 3].
In the study group using low−dose hormonal
contraception, a small increase of jitter and shim−
mer were observed compared with the control
group. Moreover, a higher variability in all the
parameters of acoustic analysis was noted in the
control group. Increased jitter and shimmer are
regarded as an indicator of a less stable process of
basic tone [6, 7]. On the other hand, Wendler et al.
found no changes in voice quality [5]. Minor
increases of jitter and shimmer as well as greater
changes in the standard deviations of these para−
meters during phonation were observed in the pre−
sent study. However, these were not statistically
significant compared with the control group,
which can be explained by the large dispersion in
the control group and its relatively small statistical
strength. The parameters describing the larger
noise component of the voice in women using hor−
monal
contraception
increased
similarly.
However, this also appeared to be statistically
insignificant. Although there are no data in the lit−
erature concerning changes in formant frequencies
during sex hormone application, a decrease in the
higher formant frequencies of the vowel “a”
appeared to be significant in the present study.
According to the present authors’ clinical observa−
tions, hormonal voice disorders often begin from
difficulties in quiet phonation. The changes noted
in the voice analysis, especially of the sentence
and the standard deviations of the formant analysis
of the vowel “a”, indicate intonation weakening
and, although these values were statistically
insignificant, the voice and formant frequency
become lower. These changes show that the vocal
folds work more irregularly, but the voice tract
configuration is more stable in women who use
hormonal contraception.
In conclusion, there were no statistically sig−
nificant changes in the parameters Jitter and
Shimmer in the group of women who used oral
hormonal contraception. Statistically significant
changes in higher formant frequencies of the
vowel “a” were observed. The use of hormonal
contraception influenced subjective voice evalua−
tion in the investigated women only to a small
degree. The use of hormonal contraception could
result in the retention of thick mucus in the larynx.
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[14] Obrębowski A.: Podstawy anatomii i fizjologii narządu głosu. W: Narząd głosu i jego znaczenie w komunikacji
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Address for correspondence:
Zygmunt Zdrojewicz
Endocrinology, Diabetology, and Isotopic Treatment Department
Wroclaw Medical University
Pasteura 4
50−367 Wrocław
Poland
Tel.: +48 71 784 25 54
E−mail: [email protected]
Conflict of interest: None declared
Received: 13.03.2009
Revised: 29.09.2009
Accepted: 19.06.2009
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