In the late nineteenth and early twentieth century it was taught that vaginal hysterectomy could not be performed if the uterus was enlarged, but uterine size was never quantified. Other suggested contraindications included a ‘narrow vagina’ (pubic arch < 90°) and a diminished bituberous diameter (< 8.0 cm). The bituberous diameter represents the distance between the ischial tuberosities (or sitting bones) which are easily palpated when the patient is in the dorsal lithotomy position. Nulliparity and “a uterus that was too high or did not come down” were also considered as contraindications to the vaginal approach, as were “intra-abdominal conditions” such as endometriosis, adhesions, previous pelvic surgery, previous cesarean section, and chronic pelvic pain.

Hysterectomy became the second most common operation performed in the USA in the middle twentieth century, but the complications related to this operation were not re-evaluated until 1982. The Collaborative Review of Sterilization (CREST) from the CDC studied the complications of abdominal and vaginal hysterectomy. For operative indications that could have been performed by either route, abdominal hysterectomy had a complication rate twice that of the vaginal approach.