Recap: Westminster Wednesdays examines singing through menopause and beyond

JAY CARTER: Jay Carter assistant professor of voice at Westminster Choir College and I'm thrilled to see you all populating on my screen this evening. A reminder that our next Westminster Wednesday session is going to be on February 16 called Deconstructing the Vocal Warm-up with Dr. Sean MaCarthur, our voice area colleague, and I hope that you'll consider joining us for that session as well. 

It is an enormous pleasure to introduce our presenter tonight, my colleague Kathy Kessler Price. She's the director of Westminster's Presser voice lab and also teaches courses in voice pedagogy for grad students and applied voice. In addition to her responsibilities during the term, she also directs our annual voice pedagogy institute.

Prior to her appointment at Westminster, she was a faculty member at Mississippi State University William Jewell College, where I got to know her very well, and Northern Virginia College there in Alexandria. Dr. Price is a highly respected authority in a number of areas related to voice pedagogy and her research into voices in transitional periods has been incredibly impactful. She's presented papers at numerous conferences including the Voice Foundation, the American Choral Directors Association, the National Association of Teachers of Singing as well as many others. 

A number of her works are also published in national journals. In acknowledgment of her contributions, NAT’s honored Dr. Price with her voice pedagogy award just prior to her appointment at Westminster. In addition to her extensive academic and research work, she has also been a very busy performer, especially as a soprano soloist and also as a conductor of the group Philomela in Washington D.C. at a D.C. based women's ensemble. So Kathy it's delightful to have you here tonight and I look forward to what you're going to present this evening, so welcome. 

KATHY PRICE: Thank you, Jay, wow what a beautiful introduction thank you. I'm going to talk about lifespan considerations for the female voice and another way that we today refer to such voices as to use the word cis women and I will use that as well women who are born or AFAB; assigned female at birth. There are lots of different ways of thinking of us these days, but those of us who possess the sort of hormonal pattern that's going to take us through various stages of menopause. 

So hormonal changes throughout our life can make singing really challenging, and when do these things occur. So we have a hopefully blissful childhood and then puberty comes, and so we have the onset of the menstrual cycle and this begins a period you may not even be aware exists, called pre-menopause. How about that, who knew that we were so designated from the time we begin this pubescent period all the way up until we hit peri-menopause.

Pre-menopause exists of monthly cycles which definitely affect the voice, there is pre-menstrual vocal syndrome that Jean Abby Bold talks about and wrote about so effectively where vocal cords swell and there's all kinds of potential distress that's associated with that perhaps pregnancy which also, of course, can change hormones and change physiology. Perhaps lactation if women are breastfeeding, and then somewhere in our 30s, 40s, 50s, we enter a time called perimenopause and usually we're not even aware that that is happening at first. It is usually up to a 10-year span and the only way we can know that we're in it is actually to take a blood test and see if our hormonal levels are changing. So that tells you something about how incredibly influential hormones are to singing, and to our lives as we grow and age.

I threw this word hysterectomy in there because it happens to a lot of us. I had an early hysterectomy surgical menopause, due to cancer, and this happens to a lot of people, and for many other reasons. I put it in here because this word hystericus refers to the womb or the uterus, and it also refers to hysteria. Hysterectomy got so named because it was thought that women would have mental illness due to disorders of the womb and the only cure was to remove the uterus so that women could return to mental stability, pretty fascinating right.

The word menopause that we associate with all of this, is actually one-year past the last period,  and so you don't even know that you are menopausal. You know you might be peri-menopausal but you don't know that you've actually had the event until you've gone through a whole year without any periods. Then you look back at the 12-months you go “oh that's when I became menopausal”, and everything after that is post-menopause, and at this time there's a decided decline in hormones over the rest of your life, if you indeed still have your ovaries. If you don't, then such as someone like myself, then you have that happen to you at an earlier age.

So why do hormonal changes matter? Well aside from the many and varied ways that hormones help us to feel better and more youthful, there are also hormone receptors in the larynx and that is just super important to know because that's why at puberty the voice grows and changes. Of course, we associate that so strongly with boys, but girls also have this change, and usually involves breathier voices, raspier voices, difficulty managing closure of the vocal folds so that you can make clear tones, etc. So this is the reason why we care about hormones, and maybe why we are given these different statuses of pre-menopause, peri-menopause menopause and post-menopause.

So with voice change, which is such a dramatic thing to us as people, come questions. You know when we're young, just like boys we might be irritated by voice change and puberty but we know something better is coming. But when we begin to experience some changes, when we're in our 40s or 50s, or maybe even as early as our 30s, maybe we're blessed and we don't experience those till we're in our 60s, but usually people are already post-menopausal or close to it by the time they're in their 60s, unless they're on hormone replacement therapy which we'll talk about more in a little bit. They begin to worry. Let me just interject this right here, if a woman that you're working with or that you know tells you, or you yourself feel that there's something not right about your voice something isn't working as it always has, you should tell that, and share that with your voice teacher if you have one, with your coach, with your choral director,  with people that you love and that will be sympathetic to that situation. Because a lot of times people say “oh you sound great I don't know what you're talking about you're just fine” and they sort of dismiss that because they don't perceive that there's anything wrong and they want to reassure you, but if you feel something isn't quite right then you're probably right. 

You know your voice more intimately than anyone, and especially singers who've spent a lifetime using their voices already. Whatever length that may be, you know we are hypersensitive to little changes, so it's important to kind of know what stage you are in life and what might be happening, and also not to deny it in yourself. 

So often I'll have older women, meaning not old women but just not really young anymore, come and they say well I just have allergies. Well maybe you do have allergies, but maybe you've had allergies for a while but now you're experiencing something a little bit more consistent. Perhaps, and if you do have allergies then it's time to get tested and get on allergy shots or some way to manage allergies because they can be managed if you do that and they're being managed then you're still having trouble then maybe it's time to look at what's going on with you in your hormonal world. 

These are questions I've actually been asked, and I always share them because I think they're poignant. Why does my friend's voice still sound fine and mine doesn't? And you know they're referring to another cis woman, and so I would say that usually if you were to ask that friend they would say the same about their own voices.  

Everybody in this period of life is going “whoa something is going on”, you know “I'm starting to try to sing and nothing comes out” or “I'm singing and I soften and as I do so my voice kind of disappears” or “I've noticed that I'm losing my high notes, I can't sing softly and high anymore”, “I can't sustain my breath all the way through a phrase as I used to be able to do” or “maybe I'm even losing my low notes”, sometimes that happens, “how can I get my voice back”, and what we have to learn in life, is that we change throughout our lives and it will still be your voice. This is your voice and it's still a wonderful instrument but it's not going to perhaps be as athletic or as responsive as it was, and it is irritating frankly that some women seem to not have any trouble and they just keep going and everything seems just great and it's like what so they may just be one of those fortunate people genetically who are not having their voice affected by these lifespan changes. Or they may be someone who's sung more chorally and less as a soloist and so they're still happy with the way their voice is being managed as a chorister. There's lots of things that can be a part of that.

But you will not get the exact same voice back, but new and better things can come. Maybe not better, that's maybe a wrong word to use, but because you wouldn't think of them as better at the time but for instance, you might gain more stability in your middle voice and more low notes, and you get to learn new repertoire. That doesn't change the sadness you have and not being able to sing those pieces with the high C's and D's that you could do, like falling off a log when you were younger. 

Can I still improve? Well, some people don't even start voice lessons until they hit peri-menopause, and they start to notice there's a problem. So these people are actually going to feel like they're singing better than ever because now they're getting techniques that they perhaps didn't have before, and this is the worst question, I hate it when I get it “will I know when to stop singing?”, almost always followed by “do I have to?” and I always choke up when I say that because I never want anyone to have to stop singing, but we have to realize that there are adjustments that we make and that we can still sing really beautifully and effectively. 

So let's examine anatomical physiological effects of aging, and aging is what takes us to peri-menopause, and menopause, and post-menopause. It is a fact of life if we are so fortunate to live longer, so what are some aging changes; muscle strength and elasticity decrease. A lot of this does have to do with loss of hormones, but there are other things in our bodies as well that are going on. The respiratory system changes, so what change is there; your lungs aren't changing specifically so much as the fact that the compliance of the chest wall changes. So when you take a breath you may not get as generous a movement of the rib cage as you could when you were younger, and what you're even more likely not to get is the ability to completely expel all the air. Because for years you've been stretching, stretching, stretching, you've also been coming this way, but just like a rubber band that's been stretched a lot, muscles that have been stretched a lot may not want to come all the way back, and so those phrases you could sing for days on one breath are no longer possible, but you learn to take more breaths. You keep more residual air in your lungs that's true of everyone as we age and so it's harder to expel all the air. 

Changes in the spine may cause the larynx to drop a little bit, and because of compression of the spine, and therefore you get perhaps a little longer pharyngeal space and/or epilary space and you actually might have a change in tone color a bit. Vocal folds may thin as they lose collagen, our body stops producing as much collagen in your 30s, so that's what keeps our skin plumped up and pretty and not have wrinkles, and helps our joints and all those things well vocal folds have it too, and they suffer from the loss of that.

Neurological issues such as something like bell's palsy for instance, and other kinds of palsy and other problems. Parkinson's etc can cause wobble and tremor in the voice and then because of loss of hormone, mucus becomes thicker and it becomes harder to clear your throat, you find yourself wanting to clear your throat frequently. Hearing loss is more common in men, yes, but it's not exclusive to them, and we all need to take care of our ears from day one. There's two kinds of conductive hearing loss, sensorineural hearing loss, and that sensorineural is the one we really want to focus on, is something that we can avoid having because it comes through damage from too many loud noises coming into our ears over time.

It's not the lecture to talk about exactly how that happens, but let me point out that any decibels 90 and over can be damaging to our ears, and we don't feel pain until 120 decibels so that's quite significant I think. Because of course if something hurts we grab our ears, but a lot of times we walk through very loud noises or put earbuds or whatever in our ears and are experiencing very loud noises, and just because it doesn't hurt we think we are okay, the New York subway for instance rolls in at 90 db. 

Ossification is when cartilage begins to change to bone, and our larynges, the larynx that we possess that houses our vocal folds, and our vocal cords they're the same thing, is made up of cartilage primarily so over time it becomes more bone-like and cartilage is more elastic. The one exception is the epiglottis that is made of a different kind of cartilage and it's intentionally made that way so that's what closes off the airway so we don't choke when we're swallowing. This begins in our 20s right, but it's not altogether a bad thing, it's what helps us stabilize and strengthen our instrument when we're young. It eventually becomes too stiff and this contributes to us not feeling like we can use our voice in the flexible way we have.

These are other related issues, one I want to point out is arthritis in the larynx, can you believe it? So there's these two cartilages that are in the rear or the posterior of the length of the larynx, and each of them holds one of the back parts of the vocal folds, and they insert into the cricoid cartilage via synovial joints, and in this place, they can actually you can actually develop arthritis, and so if you think about your body, if you have arthritis anywhere you could have arthritis there as well, similarly in your ears, you could have arthritis.

I want to mention intubation because I just had a conversation with somebody today whose mother-in-law in her 80s had a hip replacement, and they did a poor job of intubation and she now has vocal paresis or paralysis of one vocal fold, and she's very vocally fatigued all the time, and married to her husband who is partially deaf so it's an unhappy situation. So these things can happen to us as we age. It's very important to always talk to your anesthesiologist before you have any surgery, and let them know how concerned you are about how the tube is inserted and removed during surgery that you have that procedure. 

This is a healthy younger larynx, and these two strips of tissue that we see here are our two vocal folds, and this is the trachea down there and this tongue-like thing is the epiglottis, that little cartilaginous flap, that that closes off the windpipe, and in fact, the whole larynx so that nothing gets on these. So you see how pearly and pretty they are and they're sort of shining, and then you look down here at a much older and somewhat atrophied larynx and these two vocal folds look quite different, and I'm quite certain that this individual has trouble phonating, making a sound that is clear and resonant and all of that, and what does this come from? Comes from aging, it comes from loss of hormones, it also probably comes from lack of use. This could be somebody who lives alone and doesn't talk very much, much less sing, and it can also come from smoking, not this particular thing but other issues in the larynx definitely can come from that. 

So what to do about, this not the happiest of thoughts right, of what all these things are that are going on. Well the good news is our chronological age does not have to be our biological age, but we have to think of ways to reduce our biological age and one of those is that popular word for some and dreaded word for others, exercise. 

So overall body exercise because our body is our instrument. We've heard this a million times and recently I began to feel like I was losing strength and some problems with balance, and so I've started working with a personal trainer to get stronger again and I do feel so much better in that regard in both those categories, but specifically and intentionally there has to be vocal exercise. The older we get we can't take off you know a week and not sing and not pay the consequences.

So actually we need to use our voices every day if possible. Maybe have one day off a week where you don't do that, and we need to sing in small increments. I'm going to say this several times in this presentation, small increments throughout the day, not long periods of hard practice, and that includes rehearsals. So we need to use our voice 10 minutes, 10 minutes, 10 minutes, 10 minutes, 15 minutes, 20 minutes you know, but not an hour or two hours or three hours at once, and then you know about all these other things because I've given a vocal health talk here on a Westminster Wednesday before, but hormone replacement therapy is something that I haven't talked about, and that's something I am going to address right now.

So we now just call it hormone therapy, really HT used to be HRT, everything has to change you know, but back in the late 90s into the early 2000s, the women's health initiative at NIH did a huge study about women's voices. It was that big, big, big study that said that women had an increased risk for heart attack and stroke and possibly breast cancer if you were on hormone replacement for any length of time, and it scared everybody who was in that boat at that time, doctors and patients alike and it was recommended that everybody come off of that, and I remember this so well because I had an early in life hysterectomy and I was on hormone therapy, just estrogen and that was considered safer than estrogen and progesterone, but I did stay on it because I was on so much chemo for so long that it was going to be detrimental to my bones, and so I stayed on it until I had other cancers that were estrogen receptive and then I came off of them. But now it is being re-looked at because really the people who had this problem were people over 65, post-menopausal, and it was a small increase and it seemed to be related to family history of cancer, so if you are somebody who could benefit from hormone therapy you might talk with your doctor and look at your family history. Obviously, it's a personal choice and you have to take it very seriously, but it is a little bit of a fountain of youth for the voice. 

I will say when I had to go off of it after 17 years of being on it, within two months I lost an octave off the top of my vocalizing range, even though I was singing daily. Now I had a very high voice so that octave wasn't the you know, the most useful octave but still it affected my high C and my high D and B and B flat. Eventually it just kind of keeps going so I want you to be aware that that's not something to be as feared as much as it was. You could look for studies that talk about that now. 

So let's think about ways that we can actually help ourselves and each other and our students and our choir members, to do a little bit better as we experience these changes. But first I'm going to talk on this slide about how we compensate. So that especially in the early days of peri-menopause we begin to hear that we don't sound quite the way we expect to hear when we do these particular actions to sing, and we begin to adjust the technique to make the voice sound like what we want, and if you've been through this you kind of know what I'm talking about and so some of the things that change is we start to use more subglottal pressure, more breath pressure to try to kick start the voice. That's because onset can be difficult and we fear the voice is going to stop singing or stop sounding, and so we keep applying a little bit more pressure. Pressing the folds together rather than just allowing that wonderful nice oscillation, pressing it more, muscular engagement in sustained singing to increase the beauty of our tone and intensity but when we do that we're actually working too hard. We're working those tiny little vocal folds that for women are only together the size of a dime. You may know that already, but if you don't it's a very small mechanism. 

We might stiffen our posture in order to sort of brace the body to sing the way we want it to, rather than keeping that balance and fluidity in the body, as well as the strength. We find a need to breathe more frequently, and that's okay you can breathe more frequently, but sometimes singers go “no I will not, I always sang that phrase in one breath and I'm going to do it”. But what we hear toward the end of that phrase is the voice not sounding so beautiful anymore we're hearing the age creep in and so the tone usually deteriorates. So I always recommend to keep working toward that phrase in one breath but plan and practice judicial breaths, additional breaths, so that you are keeping things fresh. The voice works with that combination of air and muscle use, and we need to always be feeding it. 

Also that idea of holding the voice here in order to avoid too much vibrato right, we're told to sing without vibrato or less vibrato or make sure your vibrato stays very consistent. We hear it isn't and we begin to try to control at the laryngeal level. That's not a good idea, but what can we do? We'll talk about that in a minute. So vocal exercises are always the place to start if you feel vocally healthy. Then if you don't feel vocally healthy, the place to start is to make an appointment with a voice specialist such as a laryngologist with a specialty in voice. Not everybody can find that in their community I realize, but sometimes it's worth a trip to a big city that has expert doctors so that you are not going to someone and spending money and spinning your wheels and not really getting anywhere, because they don't really understand the voice. Your regular ENT may or may not understand the voice, your inner ear nose and throat doctor, they might have a specialist in the nose right or whatever it could be different.  

So now to get to vocal exercises, if you feel like you're ready to do this then and you don't feel that there's a vocal disorder or an illness or an injury, then it's time to sing more frequently in small increments. So lip trills are a wonderful place to start, the other is to use straws. Straw phonation has now been studied a lot, and what it shows us is that when you use your straw with your lips secured around it, singing through the straw will actually help balance your breath pressure and muscle use, and so you're getting a lot of back pressure information that helps you to relax the phonation threshold pressure that you use to sing, and so you're getting a wonderful balance there. The idea is to use your straw and then sing right after it without the straw, and see if you can kind of match the feeling, the internal feeling that you had. There's lots of other ways to use straws but this is not a presentation on straw phonation, but I really want to point that out. 

Some women feel like their voices are gapping, like their chords won't come together, and if that's the case instead of feeling that they have a pressed voice, they have the opposite problem. Too much air in the tone, and the consonant G can be so helpful for that. Like “gah”, “go”, if you say that while you're sitting there right now you can feel the action in your vocal folds you can feel them come together, just to give you a little bit more of a singing thing or something like “go get the gear”, or you can make up any phrase you want, but “go get the gear” sing it, “go get the gear” and see if you're feeling that activity there.

Also so often we're taught to do top-down exercises if somebody's having a hard time getting the vocal cords to come together, they may need to start in their chest voice, or even discover their chest voice and then bring that up a little bit more in order to build the thyroarytenoid muscle that has possibly become weak. This is not often the problem, it's usually the other way around, but I point that out for women because we do have people like that who are losing the bottom part of their voices.

Now the more typical thing is we need to ease the pressed voice that's trying so hard to work. Like it always used to sound and/or the inflexible voice, because the CT muscles, the muscles that give us this flexibility, and sort of mobility, as well help us sing higher notes, don't get as much of a workout. I'm noticing as I speak right now as we age, well really any time in our lives but I'm noticing as we age our speaking voices usually go lower. Mine was definitely that way when I was even in my 40s, I would have someone call back when we had landlines, they'd call the house and I would answer and they'd ask to speak to my mother you know. But I'm a lyric coloratura so that doesn't happen anymore because I have a lower voice. 

So if you are needing to free that voice you might look at this second exercise. I wouldn't use “la la la la la”, I just found this on the internet somewhere, but you know use a better sound, even an OOO would be very helpful there, you know do something that encourages movement and if the voice does not want to move then you've really got to work on that because you'll say “oh I hate those exercises” well that's what you need and that's why you hate it right? I'm right there with you. Staccato is also like I would say it's like little dumbbells for the vocal folds and the laryngeal muscles because you have to onset, offset, onset, offset, and a lot of people don't like staccato because of the same reason. It's hard to get that coordination right away, but do a little bit of it, you don't have to do a lot of any of it, and then play, have fun with your singing. 

So in peri-menopause is when I began to realize that I was having a hard time getting my onsets to work. You might start by putting a little HA before your AAH EE OO and then imagine the H and just sing, so you don't get that little grip at the beginning. If your vibrato is slowing down which is the typical thing that happens as we age, especially as you go higher, so instead of having like [sings] you can begin to get that. Imagine your breath going a little faster, and you can even use your hands. This helps engage the breath flow and helps sort of match the frequency of that pitch with a little bit faster air speed breath management. 

I've already talked about that a bit, you know breathe more often. There is no crime in it, nobody knew that you were going to go all the way through that phrase in one breath, but they will hear that you ran out of air or that the voice stops sounding fresh. So also teach the dropped in breath where the ribs move out, the back moves out the abdomen drops and the air drops in rather than a lifted up breath. What I call an ‘up breath’ that you see how I had to get rid of that before I could even speak more easily. 

Some women lose the low range but most of us lose the top because of the need to be highly elastic, and the vocal folds have to thin out quite a lot in order to get up to the high notes, and even if they retain, even if we retain our higher notes in peri and post-menopause we might not be able to sustain that for a long period of time. So to go up and sing a beautiful high note and come back down, but having to stay there or stay in the secondo pasado for a long period of time is exhausting, it's exhausting for everybody. 

You know when we're young and everything's working beautifully because of hormones and collagen and all the other good things, just general life energy you know, we can do it. Soft and high dynamics are hard for most mature singers. Though some singers, some women in post-menopause feel like they can only sing softly, so they need to build that TA muscle back to get a little bit more strength in the sound, but usually soft and high is the hardest thing. So I prefer to ask for a contrast, see if you can contrast and make that sound a little more personal or a little more intimate, rather than saying can you sing a pianissimo there, it's just too hard, and we tend to lose stamina especially in peri-menopause women find that to be extremely difficult, sometimes there's a lot of vocal fatigue, so, if you begin to feel vocally fatigued, stop. That's your voice talking to you, stop and just mouth it if you're in a rehearsal or stop altogether if you're just in your own practice time, and do something else and come back later. Menopausal statuses can dictate what we should be doing. 

So I've been talking about the peri-menopausal, NIH says this is ages 40-58 or through self-report, and this is the most vocally unstable period in a woman's life. You personally may not have had that, but some women go through their voices absolutely falling apart during these years, and they are so upset and so frustrated. 

A lot of laryngologists will say it's equivalent to boys of vocal change. But this stage has singers that are both younger than post-menopausal ones, and more experienced than the pre-menopausal ones, and so they often are at the height of their singing life, but they're beginning to notice those troubles. There might be range adjustments and vocal exercise protocols that need to be changed definitely, repertoire adjustments and shorter rehearsal and practice times. 

This is my group Philomela, when we sang under this lovely conductor, and you can see that most of us are in these peri and post-menopausal stages. I will say everyone then menopause happens, remember I said that's really just kind of an event and then we find ourselves post-menopausal and dealing with both hormonal change, which is just a steady decline at this point, rather than the fluctuations of hormones we get in peri-menopause, which can make us so crazy because one day the voice works great the next day it's a mess. 

In post-menopause, we begin a period of a new stabilization. It's different from when we were young but the voice becomes more reliable again, and you kind of know what you can do and you can ask more of it. But then you're going to have to keep that up, you can't sit on your laurels. You've got to practice, it's got to be important enough to you to practice every day, but in smaller intervals just like we did in peri-menopause.

Everything else is the same. Joyce Castle's a wonderful mezzo-soprano, said to me one time, I was interviewing her for my dissertation, she said “perimenopause, it's hell but then you know once you get through it”. Fine, well of course that's easy for contralto or a mezzo-soprano to say more easily than for a high soprano because you know your range isn't as affected but it is also true that you get something that's more reliable. 

So in my dissertation, quite a while ago now, though it seems like yesterday in some ways. I looked at actually 337 women, but 307 of them had useful data. You'll notice that women who are in perimenopause and took HRT dropped nonetheless, their highest average pitch was an A sharp five so C6 was the average upper pitch for pre-menopausal women that I looked at. Obviously, there were lots, somebody went up to B6 I mean there's lots of range in that area, but at this point whether they were on hormones or not, that top dropdown. 

So hormone therapy might have been helping how they felt but it wasn't necessarily helping their voice, and then post-menopausal for the people who were on or who went on hormone replacement they were able to reach, get back or retain their high Cs, but if they did not take it, it further dropped to an F sharp five, and if you look down at the very end of this note the addition of low range. Some of these women could hit a low A sharp two which is you know the lower chest voice, they could sing that note an octave lower. Some of you here today were part of my study, so thank you so much. 

Then this is just a chart I created to perhaps help teachers and maybe choral directors who do a warm-up, to see kind of what are the ranges based on those 300 women that might be comfortable, for would be the outer limits these are the upper and lower limits. So obviously you can bring it back in more, but you don't want to go outside of these for these different menopausal stages. 

Finally a little bit about choral rehearsals. Making sure that there's a physical warm-up of some kind; sometimes amateur or occasional singers don't understand the necessity for the whole body to be active, and they'll sit you know in a slump position with a cross leg, etc so make sure that you start with some kind of physicality even if they need to remain seated. Vocal exercises really are a must, they help to condition the voice and they help to instill technique. It's not just a warm-up, it is an ingraining and a reminder to the voice this is how we sing. Very repertoire and please don't demand straight tone out of most mature voices because it's so hard and they will hold and do everything they can to please you, but it will be very difficult.

Be aware when you select repertoire of range and test the tour for each voice part and adjust dynamics and even pitches if you want to don't feel too offended by that. Sing for 10 minutes and then do some other activity for five minutes and then come back to singing. So don't just sing sing sing for hour after hour, and consider when possible more frequent rehearsals that are shorter rather than one really long rehearsal, and laugh and enjoy and make playful noises. Everything doesn't have to be sung; we're still using our voice even if we're making animal sounds or just silly sounds. I want us to sing from this early stage of life into and through the end of our lives because it's so important and also this group here is something called encore,  and they kind of exist throughout the area, well throughout the United States I believe.

JAY CARTER: Fantastic, Kathy again thank you so much, for this. I've known about you doing this work for a number of years now and I've been excited to watch you become the person who knows how to speak about this and to make it accessible, and it's a wonderful thing that you've done. 

KATHY PRICE: Thank you, and it's my pleasure. It's near and dear to my heart, obviously and why did I start it? Because I was peri-menopausal and I had gone through an early hysterectomy, and I got a cyst in my vocal fold from chemotherapy acid reflux, which I still have, and so you know we sing on because we're born to sing. So we have to keep it going and it's a wonderful thing to do, and people will love it and they will not be as aware of all the things you're struggling with as you are so just know that.

JAY CARTER: Well Kathy again thank you, and thank you all for joining us.