A Conversation with Yael Bensoussan, M.D., Director of the University of South Florida Health Voice Center

Yael Bensoussan, M.D.

The human voice is an important health biomarker that can indicate a multitude of biological changes, including menopause, according to Yael Bensoussan, M.D., Director of the University of South Florida Health Voice Center. However, vocal changes are distressing for approximately 33% of women, because hormonal shifts can lead to a lower, more raspy voice.

Bensoussan and her colleague Rupal Patel, a professor at Northeastern University, recently published “Menopause and the voice: a narrative review of physiological changes, hormone therapy effects, and treatment options” in Menopause.

In addition to her role at the USF Health Voice Center, Bensoussan is the co-lead of Voice as a Biomarker of Health, part of the National Institutes of Health-funded project, Bridge2AI Consortium. The project seeks to build a database of 10,000 human voices to serve as a diagnostic tool for depression, cancer and even menopause.

Bensoussan recently sat down with Managed Healthcare Executive to explain how vocal changes impact menopausal women, why collaboration among medical professionals is key to bringing women relief and how artificial intelligence is leading the charge.

How does menopause affect women’s voices?

Menopause can affect women's voices in multiple ways.

With age, our fundamental frequency diminishes, so the pitch of our voice goes down. When we get to menopause, there's something on top of that where our voice gets rough and even sometimes lower. The complaints that we get from women going into menopause or perimenopause are, ‘My voice is very unpredictable; I sound like I'm smoking, or I sound like I'm sick all the time.’

There is some research that shows that at least 30% of women going through menopause will notice some voice changes, or changes that affect them enough to complain.

Why has this issue gone unaddressed for so long?

Women's issues often go unpursued, menopause symptoms in general.

Now a lot of people doing menopause research and advocating for women, but previously you might have been told, ‘those symptoms are normal; they are just menopause.’

People also didn't know about the menopause-related change in voice.

I think changes in voice can always be misinterpreted for reflux or fatigue or things like that.

In terms of voice specialists, there aren’t a lot of us, so people also often don't get referred to the right physician.

How would increasing collaboration between gynecologists and voice specialists bring awareness to this issue?

We need to do more research. I need to learn from the gynecologists when and how often women complain and what the appropriate hormone balance is that we need to reach.

In terms of clinical treatment, I would like to have better collaboration with family physicians and gynecologists so that they know who to refer patients to, whether that’s to me or other voice specialists.

When a woman complains about voice changes that have lasted more than a month to their gynecologist during their menopause or perimenopause, it's important for them to be referred to voice specialists.

Sometimes it's the opposite. Sometimes, I see people for voice issues, and I ask if they are on hormones, and sometimes it's the testosterone causing their issues. I'm biased because I only see the bad things that happen with testosterone, but with testosterone pellets, we see women that come into our office, and their voice is very masculine, rough and unpredictable. They're miserable and they tell me, ‘I was never told this could be a risk with taking testosterone.’ Sometimes when they stop the testosterone, their voice doesn't come back to normal.

I'm lucky that I have colleagues that I've developed relationship with that I can call up and say, ‘can you see this patient for me?’ I'll often ask patients for the number of their gynecologist and take the time to call them to discuss.

How is AI being used as a diagnostic tool?

I work with the Bridge2AI Voice Consortium. We look at voice to help us diagnose diseases and get an overall notion of health. We're building a huge human database of voices for other people to use.

The voice gives a lot of insight, and sometimes it's a general impression of overall health.

Recently, I had a friend call me, and I could tell she was pregnant from her voice. The estrogen in the body makes all the tissues swell, including the vocal cords. That causes an increase of mass in the vocal cord, which translates into a lower voice.

There are even sometimes cues that give an indication for specific diseases. In Parkinson's, the voice is often a lot softer—in the acoustic nomenclature, we call that a ‘breathy voice.’ They speak slower as well and the pitch is very monotonous, so they don't ‘sing’ as much when they speak.

In Alzheimer's, we're going to look for cues in the speech pattern, such as the length or complexity of the sentences.

What inspired your interest in menopause-related voice changes?

I've always been very passionate about the voice and what it tells us about ourselves.

I was also a singer, and when I worked in a voice center with other singers, a lot of them told me that their teachers could tell when they were on their periods because their voices got lower and rougher.

Now I work in Tampa, and my patients are a little bit older. About five years ago, I started working as the director of the USF Health Voice Center, and there was a pattern—all these women who were around 50 or 55 felt miserable about their voices. I wasn't seeing the same thing in males around the same age.

I'm not in menopause yet, but I see my friends who are around 45 or 50 going through perimenopause, and their voice is very rough.