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.

Caring for patients who have experienced trauma requires a skillset beyond basic knowledge of pelvic health assessment and intervention. With one-third of women experiencing intimate partner violence, and estimates of rape reports to formal agencies (e.g., police, medical professionals) ranging from only 5–33% (Fisher, Cullen, & Turner, 2000; Kilpatrick et al., 2007; Krebs et al., 2007; Rennison, 2002), we can safely say that the gender-based violence women uniquely experience is likely grossly under-reported.

Additionally, the World Health Organization reports that violence and sexual violence against women is a major global public health problem. Estimates published by WHO indicate that globally about 1 in 3 (30%) of women ages 15-49 worldwide have been subjected to either physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime.

In terms of violence, the vast majority is, sadly, intimate partner violence; that is, violence committed by your own partner. Further, the overall risk of any gender reporting intimate partner violence is 1 in 7 for people who identify as men, and 1 in 5 for people who identify as female, according to the last reported statistics from the CDC.

For trauma risk in general, the chance of any gender experiencing trauma, including ACEs, or Adverse Childhood Experiences, is as high as over 70%. The first comprehensive study on PTSD (post-traumatic stress disorder) and trauma in the US was not conducted until 1990, which reported that 60.7% of men and 51.2% of women reported at least one exposure to trauma. From there, the estimated population lifetime prevalence of 5.7% for men and 12.8% for women (Kilpatric et al 2013).

The statistics on violence against the LGBTQIA community are even more alarming. A survey found that transgender people (16+) are victimized over four times more often than cisgender people and that transgender women and men had higher rates of violent victimization than cisgender women and men. Overall, about 50% of the violent victimizations were not reported to police. A separate 2022 survey showed that LGBT people experienced 6.6 violent hate crime victimizations per 1,000 persons compared with non-LGBT people's 0.6 per 1,000 persons (odds ratio = 8.30, 95% confidence interval = 1.94, 14.65).

If you are working with this population, there is a long list of adverse impacts known to affect all genders who have experienced trauma, especially if they go on to develop PTSD or complex PTSD (cPTSD), and even more so if the person experienced an ACE. A traumatic event is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM5) as a direct or indirect witness (indirect means learning about the trauma of a loved one) to actual or threatened death, serious injury, or sexual violence, either of which can induce PTSD. Four symptom clusters define PTSD in the DSM5:

1. Intrusive symptoms - recurrent and unwanted memories, nightmares, flashbacks, and intense distress or physiological reactivity after exposure to traumatic reminders.
2. Avoidance symptoms - avoidance of trauma-related thoughts, feelings, or reminders.
3. Persistent negative beliefs - negative emotions related to the trauma (such as guilt, shame, anger, horror), loss of interest in significant activities, feelings of alienation from others, and an inability to experience positive or loving emotions.
4. Alterations in arousal and reactivity - irritability or aggression, self-destructive or reckless behavior, hypervigilance, exaggerated startle response, and problems with concentration and sleep.

Some of the signs of cPTSD can include:

• Behavioral difficulties (e.g. impulsivity, aggressiveness, sexual acting out, alcohol/drug misuse, and self-destructive behavior)
• Emotional difficulties (e.g. affect lability, rage, depression, and panic)
• Cognitive difficulties (e.g. dissociation and pathological changes in personal identity)
• interpersonal difficulties (e.g. chaotic personal relationships)
• Somatization (resulting in many visits to medical practitioners)

Some of the musculoskeletal and lifestyle manifestations of experiencing trauma and even just stress include:

• Musculoskeletal tension or “trauma posturing” (aka constant guarding)
• Upregulated sympathetic nervous system response (aka fight or flight)
• Increased stress hormones - adrenaline, noradrenaline, cortisol
• Low back pain
• Headaches
• Sleep disturbances due to clenching, grinding, or nightmares
• Indigestion, ulcers, IBS, bloating, impaired or slowed gastrointestinal motility
• Poor circulation due to poor breathing patterns
• Increased heart rate, blood pressure
• Decreased fertility in women and men
• Worsening or influence on PMS and perimenopause/menopause
• Sexual dysfunction including decreased sexual desire, and/or erectile dysfunction)
• Increased risk of hypertension and heart attack
• Chronic activation of the HPA Axis
• Upregulated glucocorticoids, resulting in decreased immune function and increased systemic inflammation
• Increased risk for chronic fatigue syndrome, metabolic disorders including diabetes and obesity, and depression
• Increased risk for reflux and increased swallowing issues due to laryngeal tension
• Muscle tension dysphonia
• Chronic hoarseness, laryngitis, or psychogenic dysphonia
• Poor cognitive function and executive functioning

With regard to pelvic health, Yehuda et al posit that “because some symptoms of PTSD, such as nightmares, intrusive memories, and insomnia, are so distressing and result in such great restrictions in overall quality of life, sexual dysfunction is often not presented as a top priority by treatment-seeking patients.” The researchers also cite multiple studies which no longer support that sexual dysfunction only arises from sexual trauma. They write, “studies of nonsexual trauma including combat, accidents, and criminal victimization have now also established an association with sexual dysfunction in men and women including sexual desire, arousal, orgasm, activity, and satisfaction.” For example, Cosgrove et al found that male combat-exposed veterans (n = 90) rates of erectile dysfunction were 85% in veterans with PTSD compared with 22% in veterans without PTSD.

Trauma Can Literally Steal Your Voice
Further, trauma, no matter what type, intimately impacts the voice. The condition of losing your voice after trauma is known as psychogenic dysphonia or aphonia. It is characterized by the loss of volitional control over phonation after psychological events such as anxiety, depression, conversion reaction, or personality disorders, cites Baker (2003). It can also develop after viruses, with COVID-19 bringing not just respiratory consequences but a unique multi-system impact with negative consequences for the pelvic floor, such as occurs after prolonged coughing, hospitalization, and/or intubation.

Any emotionally or psychologically taxing event that occurs in proximity to loss of vocal control must be investigated, in order to understand the qualitative variables that may be present in the voice dysfunction. It doesn’t even take trauma to steal your voice, since stress is cited as a top driver for muscle tension dysphonia.

For example, I have had multiple clinical cases where women struggle with their voice decades after experiencing sexual assault in college or in an intimate relationship, but chose to “keep it a secret” and not report it. I’ve also seen patients with post-COVID or long COVID who report severe struggles with return to exercise or full activities of daily living due to concomitant respiratory and pelvic floor difficulties. Further, I have treated patients who presented after accidental damage to the recurrent laryngeal nerve during surgery and are struggling to recover both their voice and pelvic floor function. Finally, I have countless patients who have been medically gaslit and told their voice and pelvic floor pain are unrelated.

Regardless of the reason, we have an obligation as pelvic health clinicians to provide the best evidence-informed care possible. The Voice to Pelvic Floor (V2PF) method is one such way to provide trauma-informed and psych-informed pelvic healthcare. The V2PF approach is a systems-based way to evaluate the patient looking at the connection between three diaphragms:

• The orofacial/cervico-laryngeal diaphragm
• The respiratory diaphragm
• The pelvic diaphragm

The purpose of a V2PF approach is to provide a deeper understanding of polyvagal theory, anatomy and physiology, neuropsychology, trauma-informed principles, as well as sociocultural issues that impact our world, in order to allow us to function as primary care providers in pelvic health across the lifespan.

Want more information? Learn how to assess and plan interventions using a voice-to-pelvic floor trauma-informed approach at Dr. Garner’s course – The Voice and the Pelvic Floor scheduled on September 7th, 2024.

Sources

• Kilpatrick D.G., Resnick H.S., Milanak M.E., Miller M.W., Keyes K.M., Friedman M.J.National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. J Trauma Stress2013;26: 537- 547.
• Sexual Victimization of College Women | Office of Justice Programs [WWW Document], n.d. URL https://www.ojp.gov/ncjrs/virtual-library/abstracts/sexual-victimization-college-women (accessed 8.6.24).
• CDC, 2024. About Intimate Partner Violence [WWW Document]. Intimate Partner Violence Prevention. URL https://www.cdc.gov/intimate-partner-violence/about/index.html (accessed 8.6.24).
• Campus Sexual Assault (CSA) Study | Office of Justice Programs [WWW Document], n.d. URL https://www.ojp.gov/ncjrs/virtual-library/abstracts/campus-sexual-assault-csa-study (accessed 8.6.24).
• Rennison, C.M., 2002. Rape and Sexual Assault: Reporting to Police and Medical Attention, 1992-2000: (387542004-001). https://doi.org/10.1037/e387542004-001
• Kilpatrick, D.G., Ruggiero, K.J., Acierno, R., Saunders, B.E., Resnick, H.S., Best, C.L., 2003. Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: Results from the National Survey of Adolescents. Journal of Consulting and Clinical Psychology 71, 692–700. https://doi.org/10.1037/0022-006X.71.4.692
• Flores, A.R., Meyer, I.H., Langton, L., Herman, J.L., 2021. Gender Identity Disparities in Criminal Victimization: National Crime Victimization Survey, 2017–2018. Am J Public Health 111, 726–729. https://doi.org/10.2105/AJPH.2020.306099
• First, M.B. (Ed.), 2022. Diagnostic and statistical manual of mental disorders: DSM-5-TR, Fifth edition, text revision. ed. American Psychiatric Association Publishing, Washington, DC.
• Flores, A.R., Stotzer, R.L., Meyer, I.H., Langton, L.L., 2022. Hate crimes against LGBT people: National Crime Victimization Survey, 2017-2019. PLoS One 17, e0279363. https://doi.org/10.1371/journal.pone.0279363
• Yehuda, R., Lehrner, A., Rosenbaum, T.Y., 2015. PTSD and Sexual Dysfunction in Men and Women. J Sex Med 12, 1107–1119. https://doi.org/10.1111/jsm.12856
• Cosgrove, D.J., Gordon, Z., Bernie, J.E., Hami, S., Montoya, D., Stein, M.B., Monga, M., 2002. Sexual dysfunction in combat veterans with post-traumatic stress disorder. Urology 60, 881–884. https://doi.org/10.1016/S0090-4295(02)01899-X
• Baker, J., 2003. Psychogenic voice disorders and traumatic stress experience: a discussion paper with two case reports. J Voice 17, 308–318. https://doi.org/10.1067/s0892-1997(03)00015-8
• VA.gov | Veterans Affairs [WWW Document], n.d. URL https://www.ptsd.va.gov/professional/treat/essentials/complex_ptsd.asp (accessed 8.6.24).
• Siracusa, C., Gray, A., 2020. Pelvic Floor Considerations in COVID-19. Journal of Women’s Health Physical Therapy 44, 144–151. https://doi.org/10.1097/JWH.0000000000000180

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

Dr. Ginger Garner PT, DPT, ATC-Ret is a clinician, author, educator, and longtime advocate for improving access to physical therapy services, especially pelvic health. She is the founder and CEO of Living Well Institute, where she has been certifying therapists and doctors in Medical Therapeutic Yoga & Integrative Lifestyle Medicine since 2000. She also owns and practices at Garner Pelvic Health, in Greensboro NC, where she offers telehealth and in-person wellness and therapy services. Ginger is the author of multiple textbooks and book chapters, published in multiple languages. She has also presented at over 20 conferences worldwide across 6 continents across a range of topics impacting the pelvic girdle, health promotion, and integrative practices.

Ginger is an active member of APTA, serving as the Legislative Chair for APTA North Carolina, as a Congressional Key Contact for APTA Private Practice, and in the Academy of Pelvic Health. Ginger lives in Greensboro, NC with her partner, 3 sons, and their rescue pup, Scout Finch. Visit Ginger at the websites above and on Instagram and YouTube.