Dysphonia in Cisgender-Females Secondary to Testosterone Therapy

Testosterone therapy has become increasingly available for cisgender females to address various issues, including libido, fatigue, and menopausal symptoms, despite a lack of United States Food and Drug Administration approval. This study describes 34 cisgender female patients with dysphonia and vocal virilization secondary to testosterone therapy with emphasis on clinical findings and therapy outcomes. A retrospective chart review was completed of cisgender female patients diagnosed by laryngologists at Nebraska Medicine with vocal virilization secondary to testosterone therapy from 2016-2022. Demographics, testosterone prescription, clinical and laryngoscopy evaluation, and treatment outcomes were collected for each patient, and descriptive statistical analysis was performed. Thirty-four patients were identified for inclusion. All patients were prescribed various formulations of testosterone, including topical gels, pellets, injections, pills, and compounded creams. The mean Voice Handicap Index score at presentation was 20 out of 40 (±9.5). The predominant diagnosis was muscle tension dysphonia (64.7%), with vocal fold edema being the most frequent laryngoscopy finding (64.7%). Nineteen patients underwent prescribed voice therapy; six achieved all therapy goals, twelve achieved some, but not all goals, and one patient was discharged from therapy without progress toward any goals. The remaining patients were lost to follow-up. These findings demonstrate the risk of permanent vocal virilization secondary to testosterone therapy, regardless of formulation. This is the largest case series to date that focuses on this known adverse effect. Our results suggest that voice therapy can aid in the improvement of symptoms; further research is necessary to assess efficacy in this population.