Effects of increased levels of androgens on voice and vocal folds in women with congenital adrenal hyperplasia and female-to-male transsexual persons

Abstract

Voice virilization in women may occur due to increased levels of androgens. Women with congenital adrenal hyperplasia (CAH) are at risk for voice virilization due to an enzyme deficiency that causes increased production of androgens and lack of cortisol. Female-to-male transsexual persons, trans men, are treated with testosterone, with virilization of the voice as a desired outcome. The overall aim of the project was to provide new knowledge on how female voice and vocal folds are affected by endogenous and exogenous androgen exposure, and the consequences virilization of the voice may have in a patient’s life.

Study I: Thirty-eight women with CAH and 24 age-matched controls participated. Their voices were recorded and acoustically and perceptually analyzed. Theyanswered questions about subjective voice problems. Endocrine datawere obtained from medical journals. The results showed that women with CAH spoke with significantly lower mean fundamental frequency (F0), had darker voice quality, and rated higher on the statement “my voice is a problem in my daily life” than the controls. Voice virilization was associated with late diagnosis or problems with glucocorticoid medication, but not with severity of mutation. Proper treatment with glucocorticoids is important to avoid long periods of increased androgen levels to prevent irreversible voice virilization.

Study II: Forty-two women with CAH and 43 age-matched controls filled out the Voice Handicap Index (VHI) and answered questions about voice function related to virilization. Endocrine data were obtained from medical journals. Women with CAH scored significantly higher than the controls on VHI when the results were divided into groups by voice handicap: none/mild, moderate, and severe. A virilized voice in women with CAH correlated with less voice satisfaction. Seven percent of the women with CAH had voice problems related to voice virilization. Voice virilization was associatedwith long periods of under-treatment with glucocorticoids and higher bone mineral density, confirming results and conclusions from study I. It is recommended that women with CAH who experience voice problems are referred for voice assessment.

Study III: Four women with CAH and virilized voices, and 5 female and 4 male controls participated. A procedure for magnetic resonance imaging of the vocal folds was developed. The results showed that the cross-sectional area of the thyroarytenoid (TA) muscle was larger in women with virilized voices than in female controls, and smaller than in males. The larger TA area correlated with lower F0 values obtained from acoustic analysisof habitual speech range profiles. Thus, the anatomical explanation for voice virilization may be a larger crosssectional area of the TA muscle, suggesting androgen receptors in the vocal folds. These findings need to be confirmed in a larger study.

Study IV: Fifty trans men participated in a longitudinal study. Voice assessments, performed before testosterone treatment started and regularly up to 24 months, included audiorecordings of speech and voice range profiles and self-ratings of voice function. A significant lowering of mean F0 was found after 3 months, after 6 months, and up to 12 months, when group data were congruent with reference data for males. No correlations were found between levels of testosterone, EVF, Hb, SHBG or LH, and F0 values. Lower F0 values correlated with greater satisfaction with the voice. A quarter of the participants had received voice therapy for problems associated with virilization, such as vocal fatigue or unstable voice. Voice assessment during testosterone treatment is important to detect the potentially large subgroup of trans men that needs voice therapy.