Insights from outside BJOG

Women generally have higher-pitched voices than men – by an octave on average. Women’s voices range from 165 to 255 Hz while men’s voices are deeper at 85–155 Hz and the difference is classically attributed to the testosterone surge around puberty experienced by boys when their voices “break” as their vocal cords elongate and thicken. Women’s voices tend to change through the menopause transition, with lower estrogen levels leading to fewer glandular cells in the sub-epithelial layer of the vocal cords with resultant reduced vibratory properties. This produces a lower pitch which can impact on social situations and perceived attractiveness. A recent systematic review reported that hormone replacement therapy (HRT) may be associated with a higher speaking fundamental frequency in postmenopausal women with a normal body mass index, and this has been measured at a mean 186 Hz in hormone users and 175 Hz in non-users (Lin & Wang JAMA Otol H N Surg 2020; https://doi.org/10. 1001/jamaoto.2020.2174). They conclude that HRT can be associated with a higher-pitched voice if used by women in their postmenopause. Another unexpected consequence of HRT is reported in a recent observational study as it demonstrated that menopausal hormone therapy was associated with a decreased prevalence of osteoarthritis of the knees (Jung et al. Menopause 2019;26:598–602). It is likely that further “indirect” effects – both positive and negative – will be uncovered. This does not necessarily make them indications for commencing therapy but they may be viewed as fringe benefits and certain women could find them cogent reasons for considering medication and clinicians should be informed of these unanticipated consequences (Figure 1). Cancer surveillance in older women