Application of hysteroscopic morphology in endometrial cancer diagnosis and fertility preservation: scientific insights and clinical artistry

Endometrial cancer (EC) is one of the most common gynecologic malignancies, with rising incidence in younger women. Given the favorable prognosis of early-stage disease, accurate diagnosis and effective fertility-preserving strategies are increasingly important. Hysteroscopy, enabling direct visualization of intrauterine lesions, plays a key role in both diagnosis and conservative management. This review summarizes current evidence on hysteroscopic morphological features of EC and their clinical significance. Classification based on surface architecture and atypical vascular patterns − such as glomerular and cerebroid types − provides early clues to tumor grade and prognosis. Tumor spread patterns (focal vs. diffuse) correlate with staging and survival outcomes, while hysteroscopic scoring systems enhance diagnostic precision. In fertility-preserving treatment, combining hysteroscopic resection with progestin therapy significantly improves complete remission rates and shortens treatment duration. Assisted reproductive technology further increases pregnancy and live birth outcomes post-remission. Molecular classification enables more tailored fertility-sparing strategies. Advances in imaging − such as narrow-band imaging and 5-aminolevulinic acid photodynamic diagnosis − enhance lesion detection by improving vascular visualization. Artificial intelligence–based hysteroscopic image analysis supports consistent lesion classification and fertility outcome prediction. Although concerns remain regarding retrograde dissemination, evidence affirms the safety and efficacy of hysteroscopy when properly performed. Hysteroscopic morphology, integrated with molecular profiling and advanced imaging technologies, represents a valuable and minimally invasive approach to personalized diagnosis and fertility preservation in EC.