Context: Fine needle aspiration cytology (FNAC) has become a critical step in the evaluation of thyroid nodules and distinguishing neoplastic from nonneoplastic nodules. The Bethesda system for reporting thyroid cytopathology (TBSRTC) helps in a universal diagnostic terminology for the clinicians to decide on the appropriate management and reduce the risk of unnecessary surgeries. Aims: To assess the utility of the Bethesda system of thyroid cytopathology reporting and efficacy of FNAC with histopathological correlation of subsequent surgically resected specimens. Materials and methods: The present study includes 3,212 cases with thyroid nodules that underwent FNAC over a 12-year period. The cases were categorized as per the Bethesda system and correlated with clinical features, hormonal profile, and histopathological examination (HPE). Results: Out of 3,212 cases, the most common Bethesda system category was benign (88.7%) followed by follicular neoplasm (FN) or suspicious for an FN (SFN) (7.3%). Cytohistopathological correlation was done in 298 cases and discrepancy was noted in 28 cases (9.4%). Statistical analysis showed that FNAC with the Bethesda system of reporting has a sensitivity of 83.7%, specificity of 95.4%, positive predictive value (PPV) of 92.8%, negative predictive value (NPV) of 89.3%, and diagnostic accuracy of 90.6%. Conclusion: Fine needle aspiration cytology (FNAC) is a reliable diagnostic tool in the evaluation of thyroid nodules as indicated by high sensitivity, high specificity, and low rate of surgical intervention in this large comprehensive study. The inclusion of the Bethesda system has provided a more precise cytological diagnosis to effectively guide clinicians for further management.