Outpatient diagnostic hysteroscopy is both feasible and acceptable in the overwhelming majority of cases, with a high detection rate for intrauterine pathology. This procedure may become as routine in the 21st century as D&C has been in the 20th.

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Objective To assess the feasibility and safety of performing vaginal hysterectomy on enlarged uteri the equivalent of 14 to 20 weeks of gestation in size. Design A prospective observational study. Setting The Royal Free Hospital, London. Participants Fourteen consecutive women undergoing vaginal hysterectomy for uterine fibroids up to 20 weeks in size. Interventions Vaginal hysterectomy with or without bilateral salpingo‐oophorectomy or oophorectomy. Main outcome measures Uterine size and weight, techniques used to reduce uterine size, surgical outcome, operative time, estimated operative blood loss, intra‐and post‐operative complications, duration of hospitalisation. Results The mean uterine size was 16.3 weeks (range 14 to 20 weeks). All hysterectomies were completed successfully by the vaginal route. The uteri weighed 380 to 1100 g, with a mean of 638.7 g. Bisection combined with myomectomy and morcellation were used in most cases to obtain reduction in uterine size, whereas coring was only utilised in two cases. The mean operating time was 84.3 min with a range of 30 to 150 min. The only complications were transient haematuria (n= 6) and superficial vaginal grazes (n= 5). One of the women required a blood transfusion. The mean post‐operative hospital stay was 3.7 days (range 2 to 9 days). Conclusion Enlargement of the uterus to a size equivalent to 20 weeks of gestation should no longer be considered a contraindication to vaginal hysterectomy. Many more hysterectomies should be carried out vaginally without resorting to abdominal or laparoscopic surgery.

Endometrial resection is an effective alternative to hysterectomy in women with menorrhagia.

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