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What if the moment women stop seeing their gynecologist is exactly when their cervical cancer risk matters most? Nenrot S. Gopep, a physician and public health researcher, joins the show to discuss her KevinMD article, “Menopause and the drop in cervical cancer screening.” Her research found that postmenopausal women are 24 percent less likely to receive a Pap smear compared to premenopausal women, even after controlling for insurance, age, and socioeconomic status. You will hear why the persistent myth that cervical cancer is only a concern for sexually active women is keeping older patients from getting screened, and why HPV can lie dormant for years before developing into cancer. Gopep explains how the shift away from gynecologists after menopause places greater responsibility on primary care physicians to continue screening through age 65. She also discusses the expanded availability of the HPV vaccine, what Australia’s elimination of cervical cancer teaches us about what is possible, and the specific questions patients should be asking their doctors about screening and vaccination. If you or someone you care about has put off cervical cancer screening after menopause, this episode could change that decision.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Nenrot S. Gopep. She is a physician and public health researcher. Today’s KevinMD article is “Menopause and the drop in cervical cancer screening.” Nenrot, thank you so much for joining me today.

Nenrot S. Gopep: Thank you for having me.

Kevin Pho: All right, so why don’t you briefly tell us a little bit about yourself and then the reason why you decided to share this article on KevinMD.

Nenrot S. Gopep: I am a medical doctor. I trained in Nigeria at the University of Jos, and then I started my medical residency in internal medicine. I also have an interest in population health and preventive medicine. I have a nonprofit organization that does some form of advocacy and provides free medical services and screening services to underserved populations. Because of this interest, I decided to pursue a Master’s in public health at Georgia Southern University.

During my master’s program, I worked with my supervisor, my professor, Dr. Tong, and that was how we came up with this research topic. We used the Health and Retirement Study data to assess how much women still do cervical cancer screening after they’ve transitioned through menopause. Basically, what we noticed was that women were more likely to still get screened when they are yet to go through menopause and during perimenopause. But then we noticed that as soon as they hit menopause, the rate of cervical cancer screening dropped by a very great percent. This was interesting because we do know that menopause happens around 40 to 50 years old, but cervical cancer screening is still supposed to be done until the age of 65 or thereabouts.

There are also certain factors that have to be met before women are transitioned out of cervical cancer screening. It was more like a lot of women were just not getting screened after menopause. So that is what made us interested to dig deeper.

Kevin Pho: All right. In your article, you wrote that women who have transitioned to menopause are 24 percent less likely to receive a Pap smear four years later compared to premenopausal women. Tell us more about that data during your research and the impact those findings have.

Nenrot S. Gopep: What we noticed was that postmenopausal women were less likely to still go through cervical cancer screening with a Pap smear after they had gone through menopause. The impact of this is that there is less vigilance after menopause. When we did some article reviews to review past studies, there was a particular study done in China where some women felt that they didn’t need to go through that screening because they felt that cervical cancer was sexually transmitted. This was interesting because although the virus is sexually transmitted, it has the probability of still lying dormant in the body and then manifesting as cancer later on. What was more interesting was that most cervical cancer cases occur in older women. The fact that women around this age were less likely to get screened, but were most likely at the highest risk to have cervical cancer, was worrying.

That was one of the things we found out. We also controlled for other factors because there could be other factors affecting those results, like insurance, age, and socioeconomic status. We tried to control for all these factors in our analysis, but the results still remained the same.

Kevin Pho: What are some of the reasons you think can explain the decline in cervical cancer screening after menopause?

Nenrot S. Gopep: I would say that it is the belief and maybe the perception. I think that clinicians need to do more education to women, and to people in general, to just let them know that the risk doesn’t decrease after menopause. It is still really high after menopause. I work with an organization called ACEs World. We try to advocate for cervical cancer screening and vaccination against HPV. One of the things we are trying to do is to decenter cervical cancer as just a sexually transmitted infection. Not because HPV isn’t a sexually transmitted infection, but it kind of takes people’s attention away from the many ways that it can later translate to cervical cancer.

We are trying to decenter people from that because we noticed that when people become not sexually active, or for women that have sex with women, they felt they were not at risk of having HPV and cervical cancer. When we decenter the conversation from it being a sexually transmitted infection to just something that we may need to get done regularly, then I feel like we are going to have more progress.

Kevin Pho: Tell us some of the common scenarios that you see in the exam room, or that I as a primary care physician see in the exam room. Because sometimes when I offer Pap smears and cervical cancer screenings to women, they sometimes feel it is a young woman’s disease, especially post-menopause. What are some of the myths that commonly persist, and what are some of the things that I can do in the primary care exam room to dispel some of those myths?

Nenrot S. Gopep: I think one of the things that we need to dispel is the idea that you only get cervical cancer when you are sexually active. Yes, HPV is sexually transmitted, but the Pap smear that is being done is not really detecting the viral genome. The virus could be there lying dormant and then develop into cervical cancer years later. I think we just need to tell people that even if you are not currently sexually active, you can still be at risk of developing cervical cancer if you are not screened regularly.

This is especially important because fewer women are seeing gynecologists as they go post-menopause because fewer of these women require birth control, so they are being found in the primary care setting. So it is pretty important that primary care physicians continue to emphasize the importance of cervical cancer screening as women age up until the age of 65.

Kevin Pho: What else do we have coming on the horizon when it comes to this research and messaging? What are some other things that we can do? Are you aware of any organizations that are promoting the importance of continued cervical cancer screening?

Nenrot S. Gopep: Yes, for ACEs World, we partner with a couple of organizations that are also putting the message out there and helping to improve access to the vaccine. Previously, the vaccine was only available to women up to the age of 26 or 27. Now it has been increased to around 40 years, but that is solely based on the discretion of the provider and the patient; it is a joint decision. We are pushing the message out there for people to just know that this is an option and to talk about it with their provider if it is something they will be interested in.

Also, I think the vaccine plays a very major role in helping to prevent cervical cancer. That is why it is important to talk about it to people from a younger age, especially to parents, because we have noticed that vaccine hesitancy is playing a key role in preventing the elimination of cervical cancer. We also need to talk to people and let them know that the vaccine is safe and available and they should get both male and female kids vaccinated.

Kevin Pho: For those who aren’t familiar, this is the HPV vaccine. What are the current guidelines to administer this vaccine?

Nenrot S. Gopep: The vaccine is administered starting around the age of nine. It is given between the ages of 9 to 26, and there are two doses of the vaccine, given six months apart. The vaccine is safe. So far, I don’t think it has any major side effects. It helps to prevent infection from the human papillomavirus. It is important to get it at a younger age because, like we said, it is a sexually transmitted infection. Even though cervical cancer is currently only in women, men also play a role in transmitting the virus. So it is important to vaccinate both men and women, or boys and girls, at a younger age.

Kevin Pho: Now let’s take a little bit more of a global perspective. What are some of the global attitudes towards cervical cancer screening outside of the United States?

Nenrot S. Gopep: Good news: Australia recently eliminated cervical cancer, which is a very good development. It goes to show that it is doable and a country like America that spends a lot on health care can still achieve that. For a lot of countries, people are still talking about it, but screening is a bit low, especially for postmenopausal women. Not a lot of research has been done in a lot of other countries on screening attitudes in postmenopausal women.

Kevin Pho: If patients are listening to you on this podcast, tell us the type of questions that they should be asking their physician about cervical cancer screening.

Nenrot S. Gopep: I think that is very important. I would say that they should ask if they are eligible to get the vaccine and if it is available. I would also suggest they ask their doctor how often they should get screened for cervical cancer by doing a Pap smear. There are also two types of screening. There is the DNA type of test for HPV, and then there is the Pap smear screening that takes cells from the cervix and checks for changes. They can ask if they are eligible for both or just one, and what kind of test should be done for them, because I think it varies for different age groups. It is important to know the type you are getting done and the sensitivity and specificity of those tests. I would say that those are the important questions to ask when you are with your provider.

Kevin Pho: What about women after a hysterectomy? I know that there are different scenarios regarding whether it is a total versus a partial hysterectomy, but in general, what is the approach to cervical cancer screening in women after a hysterectomy?

Nenrot S. Gopep: For women with a hysterectomy, if it is a total hysterectomy, then it is no longer necessary to have the Pap smear screening done because the cervix has already been taken out. But for women with a subtotal hysterectomy, there may still be some parts of the cervix present, and they are still at risk of developing cervical cancer if they are not screened. So for those groups of women, they should definitely get a Pap smear done.

Kevin Pho: We are talking to Nenrot S. Gopep. She is a physician and public health researcher. Today’s KevinMD article is “Menopause and the drop in cervical cancer screening.” Nenrot, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Nenrot S. Gopep: Some take-home messages would be that cervical cancer risk doesn’t disappear after menopause. It is a risk that is still present post-menopause. So it is important to continue screening. For clinicians, it is important to ensure that these women have met the criteria for exiting the screening. There are lots of criteria that have to be met before a woman can exit cervical cancer screening, so it is important to ensure that these women have fully met the criteria before exiting. Also, the vaccine is available, and it is important to talk to people and get them vaccinated, especially younger people. It is important to get them vaccinated early.

Kevin Pho: Nenrot, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Nenrot S. Gopep: Thank you so much.