This article intends to inform cisgender women who take testosterone for menopausal and other hormone related conditions who aren't intentionally seeking gender affirming voice changes. My hope is to raise awareness about the changes cisgender women may experience on low doses of testosterone.
Why is testosterone prescribed?
Testosterone is sometimes prescribed to peri- or post-menopausal women to improve their health, or get rid of undesired symptoms. A. Scott and L. Newson, noted testosterone can be used to improve libido, cognition, body composition, mood, muscle strength and bone health, or to reduce fatigue, hot flashes, and night sweats. Additionally, Chadwick et al. noted testosterone has been used in women to treat breast cancer, endometriosis, osteoporosis, and menopausal symptoms including hot flashes, sleep problems, irritability, fatigue, and decreased sex drive. These uses are off-label, as the FDA has only approved testosterone to be used with men with medical conditions related to low-testosterone levels.
Testosterone may be prescribed after oophorectomy, surgical removal of the ovaries, to replace hormones that your body no longer produces.
Testosterone may be prescribed to trans masculine people to cause a second, male puberty.
Testosterone may be prescribed to boys who are late to start puberty.
As vocally-specialized speech-language pathologists, our window into medical care is focused on voice and communication. While only you and your doctor can decide what medical treatments are right for you, we want you to be able to make informed choices about your voice. While voice change from testosterone is not guaranteed, it is always possible. This information is for informational purposes only. Please consult a doctor for your medical care.
Important Takeaways
Voice changes caused by testosterone exposure are permanent, and irreversible
Even small amounts of testosterone can have a big impact on the voice, and large dosages might not change the voice at all.
While results can be unpredictable, the likelihood of both desirable and undesirable voice change increases with higher dosages
What is testosterone?
Hormones are chemicals in our bodies that coordinate different bodily functions and regulate our sex characteristics. Starting in puberty, the hormone testosterone regulates secondary male characteristics, including vocal changes and voice deepening, All people have testosterone in their bodies, as cisgender women and AFAB (assigned female at birth) people produce small amounts of testosterone in their ovaries. In cisgender women and AFAB people, testosterone plays a key role in estrogen production, contributes to sex drive, and may help maintain bone and muscle mass. As we age, our hormone levels change. With age, menopause, and smoking the female voice deepens (Glaser, et al., 2016).
How can testosterone treatment affect the voice? (Results vary)
Testosterone causes hypertrophy of the thyroarytenoid muscles, and an increase in vocal fold mass and thickness, which results in the vocal pitch lowering (Huang, et al.), and a heavier, buzzier tone.
Lower average pitch
Huang, et al. detected that short-term testosterone administration in women was associated with dose- and concentration-dependent changes in lowering of vocal pitch. Women taking 12.5-mg or 25-mg dosages experienced significant changes to their pitch, while women taking 3-mg and 6.25-mg dosages did not. Please note that the testosterone was administered via intramuscular injections, as doses vary with this application method.
Chadwick, et al. found most women reported symptoms of decreased pitch after testosterone treatment.
Transmasculine people have long been prescribed testosterone to deepen their voices and lower their pitch, but they are typically prescribed higher dosages than are given to women. Doses may vary depending on goals, a person's unique biology, and application method.
Narrower speaking range, inability to access the upper register, and less access to higher notes
Testosterone can reduce your speaking range, so that you don't use as wide a sound band when you speak. A. Hancock, et al. found that the reduced phonation frequency range after testosterone treatment could be accomplished by an overall lowering in range, or a loss of high notes while not gaining low notes. In our clinic, we've found it is sometimes very labored to reach higher notes that used to be accessible, and that access to those notes can be inconsistent.
Chadwick, et al. found most women treated with testosterone had an inability to access the upper register.
Voice quality and stamina decline
Another finding of A. Hancock et al.'s study was that a small portion of people taking testosterone may experience limitations in vocal control, stability, power, endurance, glottal function, breathing, muscle tension/posture, and voice quality. For example, roughness or frequent pitch breaks. In our clinic, we've noticed variable vocal roughness and large pitch breaks are common. Sometimes we see people who found vocal change to be very distressing, and developed a voice disorder, such as muscle tone dysphonia, in response that then needs treatment.
Chadwick, et al. found most women treated with testosterone had vocal roughness, decreased vocal stamina, and pitch breaks.
Glaser et al, 2016 noted that "hoarseness is a common complaint with a lifetime incidence up to 47%," though causation is difficult to determine. If you do experience voice changes, voice evaluation can help determine if there are any voice concerns unrelated to testosterone treatment.
Heavy, buzzy voice
The muscle inside of your vocal folds can get stronger, just like other muscles in your body. If testosterone adds muscle mass to your vocal muscles, your vocal folds will be thicker, which sounds heavier and buzzier.
Volume may increase
It takes more air pressure to move a heavier object, like true vocal folds with more mass. Huang, et al. noted average volume increased by 3.58 dB in women taking 25-mg testosterone, which is within the 2-5 dB average volume difference between male and female speakers. Please note that the testosterone was administered via intramuscular injections, as doses vary with this application method.
Why was I not informed that voice deepening was possible?
While research has documented voice deepening in cisgender women taking low-dose testosterone treatment, these findings are not widely known. In fact, the opposite is often reported, often without basis. For example, in the guide by Scott and Newson in 2020, they state that "voice deepening does not occur if testosterone levels are kept within the female physiological range." To draw this conclusion, they referenced the meta-analysis by Achilli, et al. that did not find any significant voice change in it's reviewed articles. However, Achilli et al.'s conclusion was flawed. None of the reviewed studies measured voice change directly, and you cannot accurately draw a conclusion that no voice deepening occurred if you do not measure the voice. Only three studies references voice change at all:
One study followed cisgender women taking low-dose testosterone treatment for only eight weeks, and we know it commonly takes more than eight weeks to see voice deepening. Further, they only drew upon subjective self-report to make this conclusion (Barton, et al.), when we know voice change can occur without the subject's awareness (Huang et al.). Voice change could have occurred, and just not been noted by the subjects or interviewers.
One meta-analysis did find evidence of voice deepening in the articles they reviewed, just not sufficient data for meta-analysis (Elraiyah, et al.),
One study only considered self-report during interviews, and subjects were only prescribed .15-mg to .3-mg, a dose much smaller than used in many other studies (Davis, et al.). The fact that dose standardization has not occurred makes it difficult to draw conclusions from one study for all dosages.
Achilli et al. also cited a guide, BRITISH MENOPAUSE SOCIETY Tool for clinicians, that again stated voice deepening was not a concern, without citing any source that measured voices. Medical professionals cannot infer findings that have not been investigated.
Should my expectations be different if I have a pre-existing voice disorder?
Yes! If your vocal instrument already is not functioning properly, small changes could have more significant impact in you than in people without voice disorders. You also may be more likely to notice voice changes. Chadwick et al. noted one person's dysphonia was exacerbated immediately after testosterone treatment.
If you experienced a voice change from testosterone exposure after having a unilateral vocal fold implant that did not resolve with voice therapy, it may be possible to adjust the implant. Talk to your otolaryngologist.
Should my expectations be different if I'm a voice professional?
Yes! Singers and other voice professionals are more likely to be sensitive to small changes in their voices.
How long does it take for testosterone to affect the voice?
We've seen cisgender women who noticed vocal change starting at five days, and other women with rapid changes to their voice after just two-weeks of low dose testosterone treatment. We've also seen transgender men who experienced no voice change after years of taking large doses of testosterone.
Research also shows great variability. Irwig et al. found that some transgender men had no change in the first three months, while others had their greatest drop in pitch during that time period, and advised clinicians to counsel transgender men that the majority of voice deepening would occur within 6-9 months. They also noted that how transgender men psychologically responded to voice change and gender presentation influenced how quickly their voice deepened, with more congruent gender presentation correlating with more rapid voice deepening. Chadwick, et al. saw voice changes first manifest between 0 and 48 months.
You may not notice voice changes until you've been taking testosterone for awhile or you might notice them within days. Or, you might never experience any voice deepening. There are plenty of reports of people taking testosterone and experiencing no voice change. For example, Glaser et al., 2016 measured no significant change in 10 cisgender women's mean fundamental frequency for 12 months after starting subcutaneous testosterone implants that released approximately 1.4 mg/day.
Are "low-dose" or "micro-dosing" testosterone the same thing?
Testosterone can be prescribed at many different dosages. "Micro dosing" is the term used when prescribed less than 50-mg testosterone for transition related care. "Low-dosing" is the term used when prescribed less than 26-mg testosterone for menopause-related care, which is also known as female replacement dosages of testosterone (Glaser, et al. 2016)
Time, how testosterone is administered, dosage, and your own body can all impact how much your voice changes, and how quickly those changes occur.
But I didn't take testosterone, why did my voice change?
If your partner is taking testosterone treatment in a patch, cream or gel form, there is the possibility that it could accidentally inadvertently rub off on your skin and affect your voice. The more exposure you have, the more likely it is for it to affect your voice.
How can voice training help?
While testosterone permanently changes the voice, those changes do not have to dictate what you can do with your voice. With training, you can regain lost high notes, expand your speaking range, learn to speak with a higher average pitch, or increase the reliability of your speaking or singing voice. It can sometimes take time to behaviorally change your voice, so patience is especially helpful.
Specific treatments recommended by Chadwick, et al. for cisgender women with undesired voice changes due to testosterone treatment included the following:
Semi occluded vocal tract postures (SOVTs), for example straw phonation, bilabial fricatives, lip trills, and humming to balance register transitions more efficiently, or as lead-ins for voicing
Pitch glides to balance register transitions more efficiently
Resonance/tonal focus exercises (this recommendation combines the two fundamental voice concepts of resonance- how small or large your instrument sounds like it is, which we perceive as a brighter or darker sound, and tone- how light or heavy, and how sweet versus bored your voice sounds)
Sighing/sliding patterns
Phonatory airflow techniques
Pitch agility patterns
Stretching, massage, and manual laryngeal reposturing to relieve compensatory tension habits
Are there any other treatments if voice training doesn't help?
If you tried voice therapy and your voice didn't improve, be thoughtful about the skill level of the voice professional you were working with. Did they have adequate experience with BOTH voice masculinization training and rehabilitation voice therapy? If not, try finding a specialist to work with. If that doesn't work, there are surgical options. When voice therapy didn't work, both Dr. Thomas in Oregon and Dr. Enver in Turkey have had success with laser-assisted voice adjustment surgery. This procedure involves laser tightening of the superior vocal fold surface but, like all voice surgeries, can itself be vocally damaging.
If you're not happy with your voice change, talk to your doctor, but don't give up hope. Whatever your voice goals, a speech-language pathologist specialized in gender and identity affirming voice care can help you find a voice you love!
References:
Achilli, C.; Pundir, J.; Ramanathan, P.; Sabatini, L.; Hamoda, H.; and Panay, N. Efficacy and safety of transdermal testosterone in postmenopausal women with hypoactive sexual desire disorder: a systematic review and meta-analysis (2017). Fertility and Sterility Vol. 107, No. 2, February 2017, 0015-0282.
Barton, D.; Wender, D.; Sloan, J.; Dalton, R.; Balcueva, E.; Atherton, P.; Bernath Jr.; A.; DeKrey, W.; Larson, T.; and Bearden III, J. Randomized Controlled Trial to Evaluate Transdermal Testosterone in Female Cancer Survivors With Decreased Libido; North Central Cancer Treatment Group Protocol N02C3 (2007). Journal of the National Cancer Institute, Volume 00, Issue 9, 2 May 2007, Pages 672-679.
BRITISH MENOPAUSE SOCIETY Tool for clinicians (2022). British Menopause Society.
Chadwick, K; Simpson, C.; McGarey Jr., P.; Estes, C.; Nix, J.; and Sulica, L. Voice change following testosterone supplementation in women: a multi-institutional case series (2020). Journal of Voice, Vol. 35, No. 6, pp. 936.el-936.e7.
Davis, S.; Moreau, M.; Kroll, R.; Bouchard, C.; Panay, N.; Gass, M.; Braunstein, G.; Hirshberg, L.; Rodenberg, C.; Pack, S.; Koch, H.; and Moufarege, A. Testosterone for low libido in postmenopausal women not taking estrogen (2008). N Engl J Med; 359:2005-2007.
Elraiyah, T.; Sonbol, M.; Wang, Z.; Khairalseed, T.; Asi, N.; Undavalli, C.; Nabhan, M.; Firwana, B.; Altayar, O.; Prokop, L.; Montori, V.; and Murad, M. The benefits and harms of systemic testosterone therapy in postmenopausal women with normal adrenal function: a systematic review and meta-analysis (2014). J Clin Endocrinol Metab, 2014 Oct; 99(10): 3543-3550.
FDA (2015). Testosterone prescribing information.
Huang G.; Pencina, K.; Coady, J.; Beleva, Yusnie.; Bhasin, S., and Basaria, S. Functional voice testing detects early changes in vocal pitch in women during testosterone administration (2015). J Clin Endocrinol Metab, 100(6): 2254-2260.
Glaser, R.; York, A.; and Dimitrakakis, C. Beneficial effects of testosterone therapy in women measured by the validated Menopause Rating Scale (MRS) (2011). Maturitas, 2011 Apr;68(4):355-61.
Glaser, R.; York, A.; and Dimitrakakis, C. Effect of testosterone therapy on the female voice (2016). Climacteric, 2016 Mar 3; 19(2): 198-203
Hancock, A.; Childs, Kayla.; and Irwig, M. Trans Male Voice in the First Year of Testosterone Therapy: Make No Assumptions (2017). Journal of Speech, Language, and Hearing Research
Irwig, M.; Childs, K.; and Hancock, A. Effects of testosterone on the transgender male voice (2017). Andrology, 2017, 5, 107-112).
Scott, A.; and Newson, L. Should we be prescribing testosterone to perimenopausal and menopausal women? A guide to prescribing testosterone for women in primary care (2020). Br J Gen Pract, 2020 Apr, 70(693): 203-204.
Ready to find a voice you love? I'd love to help! Please reach out for a free phone consultation.
Tallulah Breslin, MS, CCC/SLP
Gender affirming voice care
