Decade-Stratified Malignancy Risk in Hysteroscopic Polypectomy: A Multicenter Registry Analysis of 9269 Procedures

Background: Malignancy risk in hysteroscopic polypectomy specimens rises with age and postmenopausal status, but decade-stratified absolute rates from large, unselected cohorts remain scarce, limiting the quantitative basis for pre-procedural risk counseling. Objective: To estimate decade-specific absolute malignancy rates and to determine how the documented procedural indication modifies that risk. Methods: Retrospective multicenter cohort study with SNOMED-coded histology. All hysteroscopic polypectomies at five Assuta Medical Center sites from January 2019 to April 2026 with a linked histology result constituted the analytic cohort (n = 9269; 75.1% of a base cohort of 12,339). The primary outcome was histologically confirmed endometrial malignancy, defined by SNOMED morphology and topography coding. Multivariable logistic regression adjusted for weight category, hospital site, and calendar year. Results: The overall malignancy rate was 1.63% (151/9269), increasing monotonically: 0.45% (under 50 years), 1.25% (50–59), 3.79% (60–69), and 4.58% (70 or older). Adjusted odds ratios versus the reference group were 2.02 (95% CI, 1.13–3.60), 5.77 (95% CI, 3.39–9.83), and 8.03 (95% CI, 4.51–14.30). Across all age groups, procedures with a documented postmenopausal bleeding (PMB) indication carried an overall malignancy rate of 6.32% (29/459; adjusted OR, 3.04; 95% CI, 1.96–4.72 versus incidental polyp finding); among women aged 70 or older with a documented PMB indication, the rate was 8/61 (13.1%; 95% CI, 6.8–23.8%). Procedures coded with a non-PMB uterine bleeding indication were not associated with excess malignancy risk (0.36%). Weight over 80 kg was an independent predictor of endometrial malignancy (adjusted OR, 3.05; 95% CI, 1.92–4.84). Age group and the documented PMB indication were entered as independent covariates in a single multivariable model; no significant age-by-PMB interaction was detected (likelihood ratio test p = 0.667). Conclusions: Malignancy risk rises more than tenfold from the youngest to the oldest age group. Procedures with a documented PMB indication were associated with substantially higher risk than other indications, while non-PMB bleeding was not associated with excess risk in this cohort. Age and documented procedural indication may be the most clinically useful predictors for stratifying histological examination decisions.