- Email: [email protected]
Phono-articulatory variations of women in reproductive age and postmenopausal
Phono-articulatory Variations of Women in Reproductive Age and Postmenopausal *‡Elise´a Maria Meurer, †Maria Celeste Oso´rio Wender, *†§Helena von Eye Corleta, and *†§Edison Capp Porto Alegre and Canoas, Brazil
Summary: Human verbal expression requires coordinated interaction among cortical, neuromuscular, and peripheral events. It is affected by hormonal factors and shows different characteristics in reproductive age and postmenopausal women. The present study compared phono-articulatory characteristics between women in reproductive age postmenopausal. Acoustic variations in fundamental frequency, voice sustenance, formants, vocal intensity, and verbal diadochokinesis were measured. Forty-five women in reproductive age with regular menstrual cycles and taking no hormonal contraceptives and 45 postmenopausal women receiving no hormonal replacement therapy for at least 3 years were interviewed, and their verbal productions were tape-recorded. Acoustic analyses were performed using the Kay Elemetrics Motor Speech Profile (Lincoln Park, NJ). Student t test was employed to compare data between the two groups when they presented normal distribution and MannWhitney test when they were asymmetrical. Results showed a greater variability in vocal sustenance, less variation in formants, and verbal diadochokinesis in postmenopausal women. There were no significant variations in fundamental frequency and vocal intensity. These results emphasize the need of a multidisciplinary integrated research, when assessing phono-articulatory processes after the menopause. A better understanding in this field will make it possible to elaborate strategies to offer a better life quality for postmenopausal women. Key Words: Voice—Phono-articulation—Postmenopause—Reproductive age— Speech speed.
Address correspondence and reprint requests to Elise´a Maria Meurer, Av. Independeˆncia 482/904, 90 035 071 Porto Alegre, RS, Brazil. E-mail: [email protected] Journal of Voice, Vol. 18, No. 3, pp. 369–374 0892-1997/$30.00 쑕 2004 The Voice Foundation doi:10.1016/j.jvoice.2003.02.001
Accepted for publication February 24, 2003. Supported by the FIPE/Hospital de Clı´nicas de Porto Alegre. From the *Department of Physiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; †Department of Obstetrics and Gynecology, Hospital de Clı´nicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; ‡Department of Phono-Audiology, Universidade Luterana do Brasil, Canoas, Brazil; §Clı´nica Gerar de Fertilizac¸a˜o Assistida, Porto Alegre, Brazil.
369
ELISE´A MARIA MEURER ET AL
370 INTRODUCTION
MATERIAL AND METHODS
Verbal expression is used in interpersonal relationships and represents a communication resource unique to human beings. Specific characteristics of verbal production personalize individuals. Among these factors, there is the higher or lower fundamental frequency of the speaking voice and the speed of speech. For the motor production of voice and speech (phono-articulation), interactions among cortical, subcortical, and neuromuscular systems and peripheral structures are necessary.1 Mechanics vary for the performance of the different types of speech, such as evocative, repetitive, and verbal reading.2 Women have phono-articulatory characteristics related to the actions of steroid sex hormones during their lives. In the reproductive period, the dynamic interaction among the hypothalamus, pituitary, and the ovaries determines the periodicity of the menstrual cycle and the blood levels of estrogen and progesterone.3 A slight permanent lowering of the female voice occurs during puberty because of the effects of steroid hormones.4 On days just prior to menstruation, some women may experience temporary vocal lowering.5,6 Although the age of onset of menopause has remained constant, life expectancy in women has increased substantially.7 Later in life, after spontaneous or induced menopause, some women may suffer from virilization of their voices.4,8 Hormonal replacement therapies containing androgens usually accentuate this characteristic; hormone replacement therapies containing estrogens favor the retention of premenopause vocal patterns. Variability of the vocal fundamental frequency and decreased efficiency of laryngeal stability have been observed after menopause, and they have been related to human aging.9,10 Presbyphonia, described as vocal aging, coincides with the postmenopausal period.11 In the elderly, there is a reduction in the amount of saliva in the mouth and reduction in the olfactory and gustatory senses.12 Loss of teeth and some types of denture, which are not well fitted, may represent additional problems for phono-articulation.13 The aim of our study was to investigate phonoarticulatory acoustic factors, such as fundamental vocal frequency, vocal sustenance and intensity, formants, and verbal diadochokinesis, in reproductive age and postmenopausal women.
Subjects The sample size was estimated from a pilot study with 30 women, for a statistical power of 80% and a confidence level of 0.05. On this basis, 45 women were enrolled in each group (45 in reproductive age and 45 postmenopausal). During the period from July to September 2001, women attending the Gynecology Clinic at the Hospital de Clı´nicas de Porto Alegre and volunteers from the local community were evaluated. Each subject was in good physical and mental state of well-being. They did not report hormonal treatments or any other organic, neurological, cognitive, or emotional conditions. Only nonsmokers and women without any history of voice training were included. The inclusion criteria for the reproductive age group (30 to 40 years old) were regular menstrual cycles and no use of contraceptives or hormonal medications. The inclusion criteria for the postmenopausal group were at least 3 years past menopause and no use of any hormonal therapy. This project was approved by the Ethics Committee from the Hospital de Clı´nicas de Porto Alegre, Universidade Federal do Rio Grande do Sul.
Journal of Voice, Vol. 18, No. 3, 2004
Procedures After detailed explanation of the objectives, advantages, and risks of the project, the volunteers signed an informed consent letter. They then completed a questionnaire relating to their voice, speech, mouth, diet, other habits, gynecologic status, and other associated factors (Appendix). Voice samples were collected with a digital tape recorder MiniDisc MZ-R70-S1 from Sony (Sony Corporation, Tokyo, Japan) with a Shure microphone model 16 A and Sony 74 MiniDiscs. The microphone was polar and unidirectional, with a flat band between 50 and 15000 Hz. In the range between 500 and 8000 Hz, the variation in capture was less than 4 dB with a peak between 6000 and 7000 Hz. In doing so, a higher accuracy was obtained from the recorded data. The microphone was placed and held 10 cm in front of the subject’s lips. The volunteers remained standing during the recordings to favor their phono-articulatory processes. Recordings were repeated until consistent patterns for analyses were obtained. Data were collected on a Kay
PHONO-ARTICULATORY VARIATIONS Elemetrics Computerized Speech Laboratory (CSL model 4341), and analyzed using the Motor Speech Profile (MSP) program (Kay Elemetrics Corporation, Lincoln Park, NJ). Emission of the prolonged vowel /a/ was recorded for at least 1.5 seconds. From this vowel emission, the fundamental vocal frequency (F0), lower (Flo) and higher (Fhi) frequency, standard deviation (F0 variation), and pitch were analyzed. Five repetitions of the vocal combination /iu/ were recorded, and the second, third, and fourth segments (segm) were analyzed. The variables studied were as follows: F2, magnitude of F2 variation (F2magn), minimum formant (F2 min), and maximum formant (F2 max). Five productions of the diadochokinesis (DDK) /pa ta ka/ were recorded, and the second, third, and fourth segments were selected. The rhythm pattern (DDK pattern), the speed (DDK speed), and its variation (DDK variation) and the intensity patterns and their variation were analyzed. The noise level of the recording room was measured by the software used for analyses of the phono-articulatory patterns. No interference from environmental noise was present in the analyzed recordings.
371
Statistical analysis Fo, Pitch, Fhi, Flo, F2, F2 variation, and F2 min had Gaussian distribution and were expressed as mean ⫾ standard deviation. In asymmetric situations (Fo variation, DDK, pattern, DDk speed, DDK variation, intensity pattern, intensity variation), median and interquartile range was employed. Data were compared within groups through Student t test for independent samples or Mann-Whitney for nonGaussian variables, as indicated.
menstrual cycles with regular periods of 28 days and variations of ⫾ 3 days. In the group of postmenopausal women, the mean age was 62 ⫾ 7.42 years, and the last period had occurred at least 3 years before (13.95 ⫾ 8.32 years after menopause). On the questionnaire, among women in the reproductive age group, 68.8% referred to themselves as talkative, 44% considered their hearing as good, and 48% very good. Among postmenopausal women, 46.66% considered themselves to be talkative, 42.22% to speak fast, 37.77% to speak loud or nearly scream, and 35.55% considered themselves to have some kind of hearing difficulty. A total of 31% of women in reproductive age and 73.33% of postmenopausal women reported lack of teeth and the use of loose or uncomfortable dentures. Report of physical activity was similar in both groups (40%). Comparing the recordings of the sustained vowel /a/, there was a statistically significant difference in the variation of the vocal fundamental frequency between women in reproductive age and postmenopausal (2.73Hz vs. 3.56Hz; p ⫽ 0.045, respectively) (Table 1). Fundamental frequency, pitch, and highest and lowest vocal frequency were similar between the groups. Analyzing the sound groups derived from the fundamental vocal frequency in the pharynx-mouth pathway, there was a statistically significant difference in the second formant variation between the two groups (p ⫽ 0.023), and these data are shown in Table 2. From the production of the diadochokinesis /pa ta ka/, the verbal patterns recorded were 158.70 ms with 6.30 segm/s and 227.63 ms with 4.42 segm/s (p ⫽ 0.001) for the reproductive age and postmenopausal groups, respectively (Table 3).
RESULTS
DISCUSSION
The mean age of the women in the reproductive age group was 35.61 ⫾ 3.25 years. They had normal
In postmenopausal women, vocal virilization, with lowering of the fundamental frequency of the
TABLE 1. Acoustic Values of the Sustained Vowel /a/
F0 (HZ) Pitch (ms) Fhi (Hz) Flo (Hz) F0 variation (Hz)
Reproductive age
Postmenopausal
p
206.58 ⫾ 19.43 4.88 ⫾ 0.48 213.98 ⫾ 20.75 198.29 ⫾ 21.24 2.73 (0.79–13.01)
201.92 ⫾ 29.40 5.06 ⫾ 0.77 210.74 ⫾ 31.71 188.79 ⫾ 33.98 3.56 (1.50–49.13)
0.377 0.202 0.569 0.116 0.045
Journal of Voice, Vol. 18, No. 3, 2004
ELISE´A MARIA MEURER ET AL
372
TABLE 2. Acoustic Values of the Second Formant for /iu/
F2 (Hz) F2magn (Hz) F2 min (Hz) F2 max (Hz)
Reproductive age
Postmenopausal
p
1776.86 ⫾ 254.39 387.43 ⫾ 104.88 857.07 ⫾ 251.53 2533.19 ⫾ 176.37
1655.28 Hz ⫾ 237.03 416.93 ⫾ 118.29 767.88 ⫾ 167.81 2540.93 ⫾ 240.60
0.023 0.223 0.057 0.865
voice has been described.4,8 In our study, vocal fundamental frequencies in the reproductive age group (206.58 Hz) were similar to that found in other studies (204 Hz) involving women at this age group.14 However, in the postmenopausal women, the fundamental frequency (201.92 Hz) was higher than described by other authors (180 Hz).4,8 The F0 variation of the vowel /a/ found in our subjects is consistent with slight modification of neuromuscular coordination on phonatory actions.1,15 These variations might also be related to the relationships among the mass, length, and tension of the sound source,16 its cartilage and muscular structures,11 and the viscoelastic properties of the larynx.17 The periodic and nonperiodic irregularities in vocal frequency and amplitude in postmenopausal women were not higher than 35% during emissions, suggesting that these women did not have vocal tremor.15 The minimum and maximum formants (F2 min and F2 max) were not different between reproductive age and postmenopausal groups. In these groups, the F2 max found was similar to another study in Brazil (2984 Hz),18 but lower than in a study with Spanish women (4220 Hz).19 The possibility of particular regional factors affecting language needs to be considered. Possible causes in the reduction in F2 variation among the postmenopausal women could include the following: (1) interdependent relationships between
vocal harmonics and the trophic conditions of the mucosa of the pharynx, articulations, and vocals folds4; (2) age-related laryngeal changes, such as calcification of cartilages and atrophy of the intrinsic and extrinsic muscles, may lead to changes in contractile capabilities and mucosa thinning18,20; (3) changes in bones and muscles and functional modifications of the face21,22; and (4) loss of teeth and inadequate dentures.13 In our group, 73% of the postmenopausal women were noted to have dental problems. The postmenopausal women needed more time to emit /pa ta ka/ (DDK pattern: 158.70 for reproductive age group ms vs. 227.63 ms for postmenopausal group). Consequently, they were slower to speak than women in reproductive age, but both groups had similar DDK variation. Previous studies have shown a decreased articulatory motility in postmenopausal women,23 a process that requires cortical and subcortical dynamic interactions, together with the cranial nerves and mouth structures. This may result from metabolic and structural changes related to aging such as the suppression of estrogen actions,24,25 the fatigue and weakness derived from neuromuscular diseases that affect the cortical and subcortical interactions.3 The mean values of the intensity patterns and the variations in the vocal emissions were similar in both groups studied during productions of /pa ta ka/. These values were similar to those found in other
TABLE 3. Acoustic Values of the Diadochokinesis /pa ta ka/ and Vocal Intensity Reproductive age DDK pattern (ms) DDK speed (/s) DDK variation (ms) Intensity pattern (dB) Intensity variation (dB)
Journal of Voice, Vol. 18, No. 3, 2004
158.70 6.30 52.14 63.47 1.46
(127.83–371.89) (2.69–7.82) (9.56–289.02) (56.74–73.10) (0.61–9.48)
Postmenopausal 227.63 4.42 51.86 64.00 1.77
(128.25–580.20) (1.72–7.80) (14.44–296.60) (56.56–78.30) (0.48–9.56)
p 0.001 0.001 0.360 0.225 0.750
PHONO-ARTICULATORY VARIATIONS studies (60–73.88 dB),14,16 which considered the influences of different recording techniques and analysis.26 In our study, the results suggest that the ability to make adjustments in the ventilatory and laryngeal functions, hearing self-monitoring, and speech context are preserved in the postmenopause group. These adjustments suggest effectiveness in maintaining stability in the DDK production, and they reinforce our suggestion that the variations in the vocal /a/ sustentation are caused by other structural factors previously cited. Similarities in the vocal intensity and its variations between the two groups did not confirm the perception of the postmenopausal women that they usually talk too loud, nearly screaming.
4. 5.
6.
7.
8.
9.
CONCLUSION In the present study, postmenopausal women had more variability in vocal sustenance, less variation in formants, and slower verbal diadochokinesis as compared with women of reproductive age. The slowing down of verbal diadochokinesis production, of the fundamental vocal frequency, of the vocal sustenance, and of the formants variation emphasizes the need for a better understanding of the physiologic events involved in these processes. The phono-articulatory process should be examined as an integrated system, considering its neurological, motor, psychological aspects, as well as integrated structures involving the mouth, larynx, lungs, tonsils, and nasal cavity. Further, it points out to the need of a multidisciplinary approach, when assessing phono-articulatory processes after the menopause. A better understanding in this field will make it possible to elaborate strategies to offer a better life quality for postmenopausal women.
10.
11.
12. 13.
14.
15. 16. 17.
18.
19.
REFERENCES 1. Lofqvist A, Linblom B. Speech motor control. Curr Opin Neurobiol. 1994;4:823–826. 2. Bookheimer SY, Zeffiro TA, Blaxton TA, Gaillard W, Theodore WH. Activation of language cortex with automatic speech tasks. Neurology. 2000;55:1151–1157. 3. Shoham Z, Schachter M. Estrogen biosynthesis—regulation, action, remote effects, and value of monitoring in
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ovarian stimulation cycles. Fertility Sterility. 1996;65:687– 701. Abitbol J, Abitbol P, Abitbol B. Sex hormones and the female voice. J Voice. 1999;13:424–446. Becklake MR, Kauffmann F. Gender differences in airway behaviour over the human life span. Thorax. 1999;54:1119– 1138. Brasoloto AG, Molina KL, Cristovam G, Berrentin G, Issa JP. Modificac¸o˜es na frequ¨eˆncia fundamental da voz de mulheres associada a manifestac¸o˜es de tensa˜o pre´-menstrual. Anais da Revista da Sociedade Brasileira de Fonoaudiologia. 2000,p80;87. Lindheim SR, Legro RS, Bernstein L, Stanczyk F, Vijod MA, Presser SC, Lobo RA. Behavioral stress responses in premenopausal and postmenopausal women and the effects or estrogen. Am J Obstet Gynecol. 1992;6:1831–1836. Stoichef ML. Speaking fundamental frequency characteristics of nonsmoking female adults. J Speech Hear Res. 1981; 24:437–441. Decoster W, Debruyne F. The aging voice: changes in fundamental stability and spectrum. Acta Otorrinolayngol. 1997;51:105–112. Max L, Mueller PB. Speaking Fo and cepstral periodicity analysis of conversational speech in a 105-year-old woman. J Voice. 1996;3:245–251. Behlau MS, Pontes PAL, Tosi O. Gananc¸a MM. Presbifonia: tratamento da deteriorac¸a˜o vocal inerente a idade. Acta Awho. 1988;2:245–251. Schiffman S. Taste and smell loses in normal aging and disease. JAMA. 1997;278:1357–1362. Cunha CC, Felicio CM, Bataglion C. Condic¸o˜es miofuncionais em usua´rios de pro´teses totais. Pro´-Fono. 1999;11(1): 21–26. Orlikoff RF. Vocal stability and vocal tract configuration: on acoustic and electroglottographic investigation. J Voice. 1995;9:173–181. Deliyski D. Motor speech profile model 4341. Kay Elemetrics Corp., Lincoln Park, NJ, 1997, pp. 19–40. Russo ICP. Bases fı´sicas da fonac¸a˜o. Acu´stica.aplicada a Fonoaudiologia. 1999; Lovise, SP: 143–158. Gray SD, Titze IR, Chan R, Hammond T. Vocal fold proteoglycans and their influence on biomechanics. Laryngoscope. 1999;109:845–854. Carbonell J, Tolosa F, Juan E. Presbyphonia: a study of acoustic parameters of normalcy. Acta Otorrinolaringologica Espanola. 1996;47:295–299. Behlau MS, Pontes PAL, Tosi O, Gananc¸a MM. Ana´lise espectrogra´fica de formantes da vogais do portugueˆs brasileiro. Acta Awho. 1988;2:74–85. Linville SE, Rens J. Vocal tract resonance analysis of aging voice using long-term average spectra. J Voice. 2001;15: 323–330. Tome´ B. Topography of facial ageing. Acta Medica Portuguesa. 1998;11:191–196. Hamerman D. Aging and the mukuloskeletal system. Annais of the rheumatic diseases. 1997;56:578–585. Journal of Voice, Vol. 18, No. 3, 2004
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23. Shaywitz SE, et al. Effect of estrogen on brain activation patterns in postmenopausal women during working memory tasks. Obstet Gynecol Surg. 2000;55:227–228. 24. Murphy DGM, et al. Sex differences in human brain morphometry and metabolism: an in vivo. JAMA. 1996;53:585–594.
25. Genazzani AR, et al. Neuroendocrine changes and climaterium. Maturitas. 1997;27:1–10. 26. Gelfer MP, Young SR. Comparisons of intensity measures and their stability in male and female speakers. J Voice. 1997;2:178–186.
APPENDIX. QUESTIONNAIRE 1. name (initials): ____Date of birth: ____Date:____ 2. school ( ) high school ( ) academic degree ( ) Complete ( ) Incomplete ( ) 3. Profession: _______________________ 4. voice and speech 4.1. Are you used to speak: a lot ( ) not too much ( ) very quickly ( ) very slowly ( ) in public ( ) always loud or almost screaming ( ) very low - weak ( ) 4.2 Your voice usually: fail ( ) becomes husky ( ) disappear ( ) others 4.3 How often people ask you to repeat what you have said? ( ) 4.4 How often do you have laryngeal secretion? ( ) 4.5 Do you make any vocal training to sing? ( ) To talk? ( ) 4.6 Do you think you hear very well ( ) well ( ) with some difficulty ( ) badly ( )? 5. Mouth and diet: ( ) do you feel you have more salivation lately? ( ) do you feel you have any difficult in mastication? ( ) after swallow, do you still have food in your throat, or do you choke frequently? ( ) Do you have any reflux through your nose? ( ) do you have teeth missing or use loose or uncomfortable dentures? 6. Do you practice any physical activity regularly? 7. Do you make any diet? 8. Do you drink alcohol regularly? 9. Do you stay frequently in rooms with air-conditioning? 10. Date of last menstrual period: 11. Do you have any other health conditions or disease?
Journal of Voice, Vol. 18, No. 3, 2004
Summary: Human verbal expression requires coordinated interaction among cortical, neuromuscular, and peripheral events. It is affected by hormonal factors and shows different characteristics in reproductive age and postmenopausal women. The present study compared phono-articulatory characteristics between women in reproductive age postmenopausal. Acoustic variations in fundamental frequency, voice sustenance, formants, vocal intensity, and verbal diadochokinesis were measured. Forty-five women in reproductive age with regular menstrual cycles and taking no hormonal contraceptives and 45 postmenopausal women receiving no hormonal replacement therapy for at least 3 years were interviewed, and their verbal productions were tape-recorded. Acoustic analyses were performed using the Kay Elemetrics Motor Speech Profile (Lincoln Park, NJ). Student t test was employed to compare data between the two groups when they presented normal distribution and MannWhitney test when they were asymmetrical. Results showed a greater variability in vocal sustenance, less variation in formants, and verbal diadochokinesis in postmenopausal women. There were no significant variations in fundamental frequency and vocal intensity. These results emphasize the need of a multidisciplinary integrated research, when assessing phono-articulatory processes after the menopause. A better understanding in this field will make it possible to elaborate strategies to offer a better life quality for postmenopausal women. Key Words: Voice—Phono-articulation—Postmenopause—Reproductive age— Speech speed.
Address correspondence and reprint requests to Elise´a Maria Meurer, Av. Independeˆncia 482/904, 90 035 071 Porto Alegre, RS, Brazil. E-mail: [email protected] Journal of Voice, Vol. 18, No. 3, pp. 369–374 0892-1997/$30.00 쑕 2004 The Voice Foundation doi:10.1016/j.jvoice.2003.02.001
Accepted for publication February 24, 2003. Supported by the FIPE/Hospital de Clı´nicas de Porto Alegre. From the *Department of Physiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; †Department of Obstetrics and Gynecology, Hospital de Clı´nicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; ‡Department of Phono-Audiology, Universidade Luterana do Brasil, Canoas, Brazil; §Clı´nica Gerar de Fertilizac¸a˜o Assistida, Porto Alegre, Brazil.
369
ELISE´A MARIA MEURER ET AL
370 INTRODUCTION
MATERIAL AND METHODS
Verbal expression is used in interpersonal relationships and represents a communication resource unique to human beings. Specific characteristics of verbal production personalize individuals. Among these factors, there is the higher or lower fundamental frequency of the speaking voice and the speed of speech. For the motor production of voice and speech (phono-articulation), interactions among cortical, subcortical, and neuromuscular systems and peripheral structures are necessary.1 Mechanics vary for the performance of the different types of speech, such as evocative, repetitive, and verbal reading.2 Women have phono-articulatory characteristics related to the actions of steroid sex hormones during their lives. In the reproductive period, the dynamic interaction among the hypothalamus, pituitary, and the ovaries determines the periodicity of the menstrual cycle and the blood levels of estrogen and progesterone.3 A slight permanent lowering of the female voice occurs during puberty because of the effects of steroid hormones.4 On days just prior to menstruation, some women may experience temporary vocal lowering.5,6 Although the age of onset of menopause has remained constant, life expectancy in women has increased substantially.7 Later in life, after spontaneous or induced menopause, some women may suffer from virilization of their voices.4,8 Hormonal replacement therapies containing androgens usually accentuate this characteristic; hormone replacement therapies containing estrogens favor the retention of premenopause vocal patterns. Variability of the vocal fundamental frequency and decreased efficiency of laryngeal stability have been observed after menopause, and they have been related to human aging.9,10 Presbyphonia, described as vocal aging, coincides with the postmenopausal period.11 In the elderly, there is a reduction in the amount of saliva in the mouth and reduction in the olfactory and gustatory senses.12 Loss of teeth and some types of denture, which are not well fitted, may represent additional problems for phono-articulation.13 The aim of our study was to investigate phonoarticulatory acoustic factors, such as fundamental vocal frequency, vocal sustenance and intensity, formants, and verbal diadochokinesis, in reproductive age and postmenopausal women.
Subjects The sample size was estimated from a pilot study with 30 women, for a statistical power of 80% and a confidence level of 0.05. On this basis, 45 women were enrolled in each group (45 in reproductive age and 45 postmenopausal). During the period from July to September 2001, women attending the Gynecology Clinic at the Hospital de Clı´nicas de Porto Alegre and volunteers from the local community were evaluated. Each subject was in good physical and mental state of well-being. They did not report hormonal treatments or any other organic, neurological, cognitive, or emotional conditions. Only nonsmokers and women without any history of voice training were included. The inclusion criteria for the reproductive age group (30 to 40 years old) were regular menstrual cycles and no use of contraceptives or hormonal medications. The inclusion criteria for the postmenopausal group were at least 3 years past menopause and no use of any hormonal therapy. This project was approved by the Ethics Committee from the Hospital de Clı´nicas de Porto Alegre, Universidade Federal do Rio Grande do Sul.
Journal of Voice, Vol. 18, No. 3, 2004
Procedures After detailed explanation of the objectives, advantages, and risks of the project, the volunteers signed an informed consent letter. They then completed a questionnaire relating to their voice, speech, mouth, diet, other habits, gynecologic status, and other associated factors (Appendix). Voice samples were collected with a digital tape recorder MiniDisc MZ-R70-S1 from Sony (Sony Corporation, Tokyo, Japan) with a Shure microphone model 16 A and Sony 74 MiniDiscs. The microphone was polar and unidirectional, with a flat band between 50 and 15000 Hz. In the range between 500 and 8000 Hz, the variation in capture was less than 4 dB with a peak between 6000 and 7000 Hz. In doing so, a higher accuracy was obtained from the recorded data. The microphone was placed and held 10 cm in front of the subject’s lips. The volunteers remained standing during the recordings to favor their phono-articulatory processes. Recordings were repeated until consistent patterns for analyses were obtained. Data were collected on a Kay
PHONO-ARTICULATORY VARIATIONS Elemetrics Computerized Speech Laboratory (CSL model 4341), and analyzed using the Motor Speech Profile (MSP) program (Kay Elemetrics Corporation, Lincoln Park, NJ). Emission of the prolonged vowel /a/ was recorded for at least 1.5 seconds. From this vowel emission, the fundamental vocal frequency (F0), lower (Flo) and higher (Fhi) frequency, standard deviation (F0 variation), and pitch were analyzed. Five repetitions of the vocal combination /iu/ were recorded, and the second, third, and fourth segments (segm) were analyzed. The variables studied were as follows: F2, magnitude of F2 variation (F2magn), minimum formant (F2 min), and maximum formant (F2 max). Five productions of the diadochokinesis (DDK) /pa ta ka/ were recorded, and the second, third, and fourth segments were selected. The rhythm pattern (DDK pattern), the speed (DDK speed), and its variation (DDK variation) and the intensity patterns and their variation were analyzed. The noise level of the recording room was measured by the software used for analyses of the phono-articulatory patterns. No interference from environmental noise was present in the analyzed recordings.
371
Statistical analysis Fo, Pitch, Fhi, Flo, F2, F2 variation, and F2 min had Gaussian distribution and were expressed as mean ⫾ standard deviation. In asymmetric situations (Fo variation, DDK, pattern, DDk speed, DDK variation, intensity pattern, intensity variation), median and interquartile range was employed. Data were compared within groups through Student t test for independent samples or Mann-Whitney for nonGaussian variables, as indicated.
menstrual cycles with regular periods of 28 days and variations of ⫾ 3 days. In the group of postmenopausal women, the mean age was 62 ⫾ 7.42 years, and the last period had occurred at least 3 years before (13.95 ⫾ 8.32 years after menopause). On the questionnaire, among women in the reproductive age group, 68.8% referred to themselves as talkative, 44% considered their hearing as good, and 48% very good. Among postmenopausal women, 46.66% considered themselves to be talkative, 42.22% to speak fast, 37.77% to speak loud or nearly scream, and 35.55% considered themselves to have some kind of hearing difficulty. A total of 31% of women in reproductive age and 73.33% of postmenopausal women reported lack of teeth and the use of loose or uncomfortable dentures. Report of physical activity was similar in both groups (40%). Comparing the recordings of the sustained vowel /a/, there was a statistically significant difference in the variation of the vocal fundamental frequency between women in reproductive age and postmenopausal (2.73Hz vs. 3.56Hz; p ⫽ 0.045, respectively) (Table 1). Fundamental frequency, pitch, and highest and lowest vocal frequency were similar between the groups. Analyzing the sound groups derived from the fundamental vocal frequency in the pharynx-mouth pathway, there was a statistically significant difference in the second formant variation between the two groups (p ⫽ 0.023), and these data are shown in Table 2. From the production of the diadochokinesis /pa ta ka/, the verbal patterns recorded were 158.70 ms with 6.30 segm/s and 227.63 ms with 4.42 segm/s (p ⫽ 0.001) for the reproductive age and postmenopausal groups, respectively (Table 3).
RESULTS
DISCUSSION
The mean age of the women in the reproductive age group was 35.61 ⫾ 3.25 years. They had normal
In postmenopausal women, vocal virilization, with lowering of the fundamental frequency of the
TABLE 1. Acoustic Values of the Sustained Vowel /a/
F0 (HZ) Pitch (ms) Fhi (Hz) Flo (Hz) F0 variation (Hz)
Reproductive age
Postmenopausal
p
206.58 ⫾ 19.43 4.88 ⫾ 0.48 213.98 ⫾ 20.75 198.29 ⫾ 21.24 2.73 (0.79–13.01)
201.92 ⫾ 29.40 5.06 ⫾ 0.77 210.74 ⫾ 31.71 188.79 ⫾ 33.98 3.56 (1.50–49.13)
0.377 0.202 0.569 0.116 0.045
Journal of Voice, Vol. 18, No. 3, 2004
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372
TABLE 2. Acoustic Values of the Second Formant for /iu/
F2 (Hz) F2magn (Hz) F2 min (Hz) F2 max (Hz)
Reproductive age
Postmenopausal
p
1776.86 ⫾ 254.39 387.43 ⫾ 104.88 857.07 ⫾ 251.53 2533.19 ⫾ 176.37
1655.28 Hz ⫾ 237.03 416.93 ⫾ 118.29 767.88 ⫾ 167.81 2540.93 ⫾ 240.60
0.023 0.223 0.057 0.865
voice has been described.4,8 In our study, vocal fundamental frequencies in the reproductive age group (206.58 Hz) were similar to that found in other studies (204 Hz) involving women at this age group.14 However, in the postmenopausal women, the fundamental frequency (201.92 Hz) was higher than described by other authors (180 Hz).4,8 The F0 variation of the vowel /a/ found in our subjects is consistent with slight modification of neuromuscular coordination on phonatory actions.1,15 These variations might also be related to the relationships among the mass, length, and tension of the sound source,16 its cartilage and muscular structures,11 and the viscoelastic properties of the larynx.17 The periodic and nonperiodic irregularities in vocal frequency and amplitude in postmenopausal women were not higher than 35% during emissions, suggesting that these women did not have vocal tremor.15 The minimum and maximum formants (F2 min and F2 max) were not different between reproductive age and postmenopausal groups. In these groups, the F2 max found was similar to another study in Brazil (2984 Hz),18 but lower than in a study with Spanish women (4220 Hz).19 The possibility of particular regional factors affecting language needs to be considered. Possible causes in the reduction in F2 variation among the postmenopausal women could include the following: (1) interdependent relationships between
vocal harmonics and the trophic conditions of the mucosa of the pharynx, articulations, and vocals folds4; (2) age-related laryngeal changes, such as calcification of cartilages and atrophy of the intrinsic and extrinsic muscles, may lead to changes in contractile capabilities and mucosa thinning18,20; (3) changes in bones and muscles and functional modifications of the face21,22; and (4) loss of teeth and inadequate dentures.13 In our group, 73% of the postmenopausal women were noted to have dental problems. The postmenopausal women needed more time to emit /pa ta ka/ (DDK pattern: 158.70 for reproductive age group ms vs. 227.63 ms for postmenopausal group). Consequently, they were slower to speak than women in reproductive age, but both groups had similar DDK variation. Previous studies have shown a decreased articulatory motility in postmenopausal women,23 a process that requires cortical and subcortical dynamic interactions, together with the cranial nerves and mouth structures. This may result from metabolic and structural changes related to aging such as the suppression of estrogen actions,24,25 the fatigue and weakness derived from neuromuscular diseases that affect the cortical and subcortical interactions.3 The mean values of the intensity patterns and the variations in the vocal emissions were similar in both groups studied during productions of /pa ta ka/. These values were similar to those found in other
TABLE 3. Acoustic Values of the Diadochokinesis /pa ta ka/ and Vocal Intensity Reproductive age DDK pattern (ms) DDK speed (/s) DDK variation (ms) Intensity pattern (dB) Intensity variation (dB)
Journal of Voice, Vol. 18, No. 3, 2004
158.70 6.30 52.14 63.47 1.46
(127.83–371.89) (2.69–7.82) (9.56–289.02) (56.74–73.10) (0.61–9.48)
Postmenopausal 227.63 4.42 51.86 64.00 1.77
(128.25–580.20) (1.72–7.80) (14.44–296.60) (56.56–78.30) (0.48–9.56)
p 0.001 0.001 0.360 0.225 0.750
PHONO-ARTICULATORY VARIATIONS studies (60–73.88 dB),14,16 which considered the influences of different recording techniques and analysis.26 In our study, the results suggest that the ability to make adjustments in the ventilatory and laryngeal functions, hearing self-monitoring, and speech context are preserved in the postmenopause group. These adjustments suggest effectiveness in maintaining stability in the DDK production, and they reinforce our suggestion that the variations in the vocal /a/ sustentation are caused by other structural factors previously cited. Similarities in the vocal intensity and its variations between the two groups did not confirm the perception of the postmenopausal women that they usually talk too loud, nearly screaming.
4. 5.
6.
7.
8.
9.
CONCLUSION In the present study, postmenopausal women had more variability in vocal sustenance, less variation in formants, and slower verbal diadochokinesis as compared with women of reproductive age. The slowing down of verbal diadochokinesis production, of the fundamental vocal frequency, of the vocal sustenance, and of the formants variation emphasizes the need for a better understanding of the physiologic events involved in these processes. The phono-articulatory process should be examined as an integrated system, considering its neurological, motor, psychological aspects, as well as integrated structures involving the mouth, larynx, lungs, tonsils, and nasal cavity. Further, it points out to the need of a multidisciplinary approach, when assessing phono-articulatory processes after the menopause. A better understanding in this field will make it possible to elaborate strategies to offer a better life quality for postmenopausal women.
10.
11.
12. 13.
14.
15. 16. 17.
18.
19.
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APPENDIX. QUESTIONNAIRE 1. name (initials): ____Date of birth: ____Date:____ 2. school ( ) high school ( ) academic degree ( ) Complete ( ) Incomplete ( ) 3. Profession: _______________________ 4. voice and speech 4.1. Are you used to speak: a lot ( ) not too much ( ) very quickly ( ) very slowly ( ) in public ( ) always loud or almost screaming ( ) very low - weak ( ) 4.2 Your voice usually: fail ( ) becomes husky ( ) disappear ( ) others 4.3 How often people ask you to repeat what you have said? ( ) 4.4 How often do you have laryngeal secretion? ( ) 4.5 Do you make any vocal training to sing? ( ) To talk? ( ) 4.6 Do you think you hear very well ( ) well ( ) with some difficulty ( ) badly ( )? 5. Mouth and diet: ( ) do you feel you have more salivation lately? ( ) do you feel you have any difficult in mastication? ( ) after swallow, do you still have food in your throat, or do you choke frequently? ( ) Do you have any reflux through your nose? ( ) do you have teeth missing or use loose or uncomfortable dentures? 6. Do you practice any physical activity regularly? 7. Do you make any diet? 8. Do you drink alcohol regularly? 9. Do you stay frequently in rooms with air-conditioning? 10. Date of last menstrual period: 11. Do you have any other health conditions or disease?
Journal of Voice, Vol. 18, No. 3, 2004