Epidemiological Profile of High-Risk HPV in Cervical Samples for Liquid-Based Cytology: Insights from Screening and Symptomatic Cohorts

High-risk human papillomavirus (HR-HPV) infection is the principal etiological factor in cervical cancer, with genotype distribution and cytological associations varying across populations. This retrospective study aimed to characterize the prevalence and genotype distribution of HR-HPV among 1747 Bulgarian women, including a subgroup of 1134 women with paired HPV polymerase chain reaction (PCR) and liquid-based cytology (LBC) results. The study population comprised women undergoing routine cervical screening (76.0%, n = 1328) and women tested because of clinical indications, including gynecological symptoms (24.0%, n = 419). The overall HR-HPV prevalence was 31.4% (549/1747) and was significantly higher among women tested for clinical indications than among those undergoing routine screening. HPV16 was the most frequently detected genotype, followed by multiple HR-HPV infections and other genotypes, including HPV31, HPV51, HPV66, HPV18, HPV45, HPV56, HPV68, and HPV33. Cytological abnormalities were identified in 24.7% (280/1134) of women with paired HPV and cytology results. HR-HPV positivity was strongly associated with abnormal cytology; however, 27.3% (233/854) of women with negative cytology were also HR-HPV positive. Integrating HPV genotyping with cytology may improve risk stratification and support more targeted clinical management. Despite the increasing use of LBC and HPV co-testing, comparative data describing HR-HPV genotype distribution and its relationship with cytological findings in screening and symptomatic populations remain limited. These findings provide epidemiological evidence on HR-HPV infection patterns in Bulgarian women and establish a foundation for future studies evaluating genotype-specific risks, disease progression, and population-based surveillance strategies.