Diagnostic Accuracy and Concordance of Hysteroscopy for Detecting Premalignant and Malignant Endometrial Lesions: A Retrospective Study From a Tertiary Center in Mexico

Background Hysteroscopy is widely regarded as the gold standard for the evaluation of intrauterine pathology due to its ability to provide direct visualization of the endometrium. In patients with suspected endometrial disease, the primary clinical objective is to exclude malignancy and identify premalignant precursor lesions such as endometrial intraepithelial neoplasia (EIN). However, the diagnostic performance of visual hysteroscopic impression compared to histopathology remains variable. This study aimed to assess the diagnostic accuracy and concordance between hysteroscopic findings and histopathological results in a tertiary care center in Mexico. Methods An observational, cross-sectional, retrospective analytical study was conducted, including 397 patients who underwent hysteroscopy between January 2024 and December 2025. The surgeon’s visual impression (index test) was compared with the histopathological diagnosis obtained from directed biopsy (reference standard). Diagnostic performance was evaluated through sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Concordance between both methods was assessed using Cohen’s kappa coefficient. Results The mean age of the study population was 48.8 years, and 36.3% were postmenopausal. Hysteroscopic findings suggested malignancy in 9.8% of cases. A total of 41 patients were identified with high-risk endometrial pathology, including endometrial hyperplasia and EIN/atypical endometrial hyperplasia (AEH). Hysteroscopy demonstrated a sensitivity of 60.97% and a specificity of 96.06%. The PPV was 64.1%, while the NPV reached 95.53%. The Cohen’s kappa coefficient was 0.541, indicating moderate agreement between hysteroscopic impression and histopathological findings. Conclusions Hysteroscopy is a valuable diagnostic tool for excluding high-risk endometrial pathology, given its high specificity and NPV. However, its moderate sensitivity limits its reliability for definitive diagnosis of premalignant and malignant lesions. These findings highlight the necessity of performing directed biopsies for histopathological confirmation, particularly in cases with suspicious visual findings.