Although described in antiquity, the real dawn of uterine surgery was in the mid-19th century when hysterectomy was occasionally performed vaginally, usually for cancer or prolapse. Then, as now, women experienced symptoms of bleeding and pain emanating from the uterus, and when severe and debilitating, brave surgeons and patients sometimes explored hysterectomy as an alternative. Abdominal hysterectomy mortality rates in the mid-1850s were extremely high, but reduced drastically in the early to mid-20th century. By the 1950s, total hysterectomy supplanted supracervical techniques, largely as a method for preventing carcinoma of the cervix. Surgical alternatives to hysterectomy started in the 1930s with abdominal myomectomy and the first publication of nonhysteroscopic endometrial ablation from Germany, but by the end of the 20th century, included a plethora of techniques including laparoscopic, hysteroscopic, and interventional radiologic approaches. The advent of early detection of, and even prevention of, preinvasive cervical neoplasia, has led to a reevaluation of the need for total hysterectomy in many patients. In the early years of the millennium, targeted leiomyoma therapy was under development with a range of energy sources including cryogenic and radiofrequency probes, as well as focused ultrasound, targeted and controlled by magnetic resonance imaging.