The Voice and the Pelvic Floor

Menopause represents a transformative phase in a woman’s life, and as pelvic health practitioners, it’s an opportunity for us to make a significant impact. Rather than being the “beginning of the end,” menopause can usher in a new era of freedom and empowerment. Women spend a significant portion of their lives post-menopause, free from the limitations of periods, pain, and hormonal fluctuations, but only if we, as clinicians, provide the tools and education necessary to thrive during this transition.

Historically, women’s health during menopause has been overlooked. In the past century, limited life expectancy meant menopause healthcare and research were rarely prioritized. Combine that with the research gap in women’s health and well-documented medical misogyny, and one can see how generations of women’s health has been neglected. However, with advancements in healthcare and advocacy, that’s changing—and we need to lead the way in reframing menopause management, starting with conservative pelvic health approaches before defaulting to hormonal therapies.

The Overlooked Connection: Hormones, Voice, and Pelvic Floor Health
Among the myriad symptoms of menopause, the interplay between hormonal changes, the voice, and the pelvic floor often goes unnoticed. Hormonal shifts, especially decreasing estrogen levels, significantly impact voice quality, including reduced pitch range, vocal endurance, and an increase in vocal fatigue and dryness. These changes mirror similar phenomena in the pelvic floor, where decreased tissue elasticity, sarcopenia, and altered pressure management can result in incontinence, prolapse, or pain.

The voice is highly sensitive to endocrine changes throughout life. For example:

• Puberty: Testosterone lengthens and thickens the vocal folds, lowering pitch.
• Menstrual Cycle: Dysphonia premenstrualis, linked to inflammation and hormonal fluctuations, reduces vocal range and endurance.
• Pregnancy: Thickened vocal folds and decreased pitch are common due to hormonal and fluid changes.

During menopause, these shifts intensify. A study in Menopause revealed that 46% of postmenopausal women experience voice changes, with 33% reporting significant quality-of-life impacts, such as reduced confidence and professional standing.

Menopause, Hormone Therapy, and the Voice
Take puberty for example, when the presence of testosterone changes the dimensions of the male vocal tract. The vocal folds become thicker and longer and the larynx size increases, which changes the “fundamental frequency of the voice.” By contrast, premenstrual voice changes have also been noted, which is known as dysphonia premenstrualis and is characterized by a loss of ability to achieve high notes, as well as vocal fatigue and reduced vocal range. Some of these changes are driven by inflammation, mucosal dryness, and decreased mucosal secretions caused by progesterone. Other researchers have noted that cervical and laryngeal smears, taken during the premenstrual period phase consistent with progesterone peak, were indistinguishable.

Likewise, women going through pregnancy, and specific to the menopause discussion, experience unique voice changes as well. Vocal abnormalities noted in the literature include vocal fold thickening, lowered vocal pitch, vocal fatigue, reduced vocal range, and failure to reach higher notes. Though anecdotally I have also seen women struggle with mid-range notes rather than high-range notes in clinical practice, which underscores the importance of evaluating each patient case-by-case instead of making broad assumptions about voice and pelvic health during perimenopause and menopause.

Of additional concern is the change that HT can have on the vocal folds, which overall can be positive. HT can improve glandular secretions above and below the vocal folds, enhance mucosal viscosity, increase pitch range, capillary permeability, and overall better tissue oxygenation. Estrogen is also a well-known inflammatory mediator, which can help protect and prevent damage to the vocal folds. Additionally, sarcopenia is known to impact vocal fold shape, which could lead to vocal fold bowing, vocalis atrophy, and subsequent glottal fold closure impairment.

The Voice-Pelvic Floor Connection (V2PF)
The interconnectedness of the voice, respiratory diaphragm, and pelvic diaphragm provides a unique lens for menopause care. These three diaphragms share connective tissue and neuromuscular pathways, which influence pressure regulation essential for vocalization, continence, and core stability.

The V2PF Method offers a systems-based, trauma-informed approach to evaluating and addressing these connections. By focusing on:

1. The orofacial/cervico-laryngeal diaphragm,
2. The respiratory diaphragm, and
3. The pelvic diaphragm,

Clinicians can help patients improve coordination, endurance, and strength across these systems. Techniques like musculoskeletal ultrasound imaging allow practitioners to assess and enhance pressure management strategies, leading to improved vocal and pelvic floor outcomes.

Empowering Women Through Education and Treatment
While hormone therapy (HT) can improve vocal function by increasing glandular secretions and reducing inflammation, among other benefits, it’s not a one-size-fits-all solution. Clinicians should consider HT as part of a comprehensive plan that includes conservative interventions such as manual therapy, exercise, and lifestyle modifications tailored to individual needs. Understanding the hormonal and structural changes of menopause empowers both practitioners and patients. With a holistic and interdisciplinary method like the V2PF approach, we can help women reclaim their voices—literally and metaphorically—during menopause.

Learn More
Join Dr. Garner's course The Voice and the Pelvic Floor at Herman and Wallace scheduled on March 8th and October 5th, 2025 to explore the V2PF method and its applications in pelvic health. Together, we can revolutionize care for women navigating menopause.

Want resources for patient education? Start here: https://youtube.com/playlist?list=PLssRl7MibHhHdVqWHIkrAp51PaYecA9d0&si=nptOLwRPbcpoJAi2

Struggling with vocal and perimenopause or menopause issues as a healthcare provider? Ginger provides first consults free at www.garnerpelvichealth.com

Resources:

1. Afsah, O. Effects of hormonal changes on the human voice: a review. Egypt J Otolaryngol, 40, 22 (2024).
2. Abitbol J, Abitbol P, Abitbol B. Sex hormones and the female voice. J Voice. 1999 Sep;13 (3): 424-46.
3. D’haeseleer E, Depypere H, Van Lierde K, (2013) Comparison of speaking fundamental frequency between premenopausal women and postmenopausal women with and without hormone therapy. Folia Phoniatr Logop 65: 78–83
4. McCarthy, M., Raval, A.P. The peri-menopause in a woman’s life: a systemic inflammatory phase that enables later neurodegenerative disease. J Neuroinflammation, 17, 317 (2020)
5. Bensoussan T, et al. Voice as a predictor of health during menopause. Presented at: Annual Meeting of The Menopause Society; Sept. 10-14, 2024; Chicago.
6. Schneider B, van Trotsenburg M, Hanke G, Bigenzahn W, Huber J. Voice impairment and menopause. Menopause. 2004 Mar-Apr; 11 (2): 151-8.
7. Awan, S. N. (2006). The aging female voice: Acoustic and respiratory data. Clinical Linguistics & Phonetics, 20 (2–3), 171–180. https://doi-org.elon.idm.oclc.org/10.1080/02699200400026918
8. https://www.nursinginpractice.com/clinical/womens-health/menopause-confidence-loss-and-the-voice/?utm_source=chatgpt.com
9. https://hermanwallace.com/blog/trauma-and-the-voice-to-pelvic-floor-connection

AUTHOR BIO:
Dr. Ginger Garner PT, DPT, ATC-Ret

Ginger Garner, PT, DPT, ATC-Ret, is a board-certified specialist in lifestyle medicine and an orthopedic and pelvic health therapist with advanced training in MSK ultrasound, dry needling, visceral and fascial mobilization, integrative, and functional medicine, including yoga, Pilates, mindfulness, and hormone health. A UNC-Chapel Hill graduate, Dr. Garner is the author of multiple textbooks, book chapters, and articles. Based in Greensboro, NC, she owns Garner Pelvic Health, hosts The Vocal Pelvic Floor podcast, and serves in multiple leadership, advocacy, and policy roles at the state and federal levels. Her clinical work focuses on voice to pelvic floor trauma-informed care for complex conditions including endometriosis, perimenopause and menopause care, hypermobility syndrome, and hip dysplasia.

Visit Dr. Garner at her clinical practice, Garner Pelvic Health, Living Well Institute, www.integrativelifestylemed.com, and on Instagram and YouTube @drgingergarner.com.