Cervicovaginal Microbiome Signatures Across Cervical Disease States: A Prospective Cross-Sectional Analysis

<b>Background/Objectives</b>: The cervicovaginal microbiome has emerged as a critical determinant of cervical health. In this study, we aimed to characterize the cervicovaginal microbiome across a spectrum of cervical health states and to identify community-level features that distinguish invasive disease from precursor states. <b>Methods</b>: We analyzed cervicovaginal samples of 86 patients with normal epithelium, low-grade (LSIL) and high-grade (HSIL) intraepithelial lesions, and cervical carcinoma (CCU) and available HPV genotyping. Vaginal samples were subjected to full-length 16S rRNA gene sequencing and genus-level taxonomic profiles were generated using ONT-supported workflows. Microbiome diversity and composition were assessed using Aitchison-based beta-diversity, non-parametric testing, and PERMANOVA. Differential abundance was evaluated using ANCOM-BC2 with false discovery rate correction. Disease-associated community shifts were quantified using log-ratio indices and co-occurrence network analysis. <b>Results</b>: Microbial diversity increased with disease severity, with cervical cancer showing the highest alpha diversity and distinct community composition. Normal samples were uniformly dominated by <i>Lactobacillus</i>, whereas LSIL and HSIL exhibited transitional communities with partial loss of lactobacillar dominance and increasing representation of anaerobic taxa. Cervical cancer was associated with depletion of <i>Lactobacillus</i> and expansion of anaerobic consortia. A <i>Lactobacillus</i>-to-anaerobe log-ratio declined monotonically with disease severity and robustly discriminated invasive cancer from precursor states. Microbial co-occurrence networks became progressively more structured with disease severity, transitioning to dense anaerobic networks in cervical cancer. <b>Conclusions</b>: Cervicovaginal microbiome signatures reflect cervical disease stage and may complement existing screening and risk stratification strategies.