Objective: To compare the perioperative outcomes of women with an enlarged uterus (≥ 250 g) who had abdominal and vaginal hysterectomies. Method: Retrospective study of the perioperative outcomes of 288 consecutive women with an enlarged uterus, of whom 200 underwent an abdominal hysterectomy and 88 a vaginal hysterectomy, all for benign gynecological conditions. Results: Among the perioperative complications, only the risk of ileus was significantly higher in the group that underwent abdominal hysterectomy. Although the need for blood transfusions was similar between the groups, mean perioperative hemoglobin change was significantly lower for women who had the abdominal approach. Vaginal hysterectomy shortened the length of hospitalization significantly but did not affect the operative time. All of these differences remained significant after adjusting for uterine weight (P<0.05). Baseline characteristics were similar between the groups, except for uterine weight. Conclusions: For women with a uterus weighing 250 g or more, vaginal hysterectomy shortens the hospital stay without significantly increasing perioperative morbidity when compared with the abdominal route. Objective: To compare the perioperative outcomes of women with an enlarged uterus (≥ 250 g) who had abdominal and vaginal hysterectomy. Method: Retrospective study of the perioperative outcomes of 288 consecutive women with an enlarged uterus, of whom 200 underwent an abdominal hysterectomy and 88 a vaginal hysterectomy, all for benign gynecological conditions. Results: Among the perioperative complications, only the risk of ileus was significantly higher in the group that underwent abdominal hysterectomy. Although the need for blood transfusions was similar between the groups, mean perioperative hemoglobin change was significantly lower for women who had the abdominal approach. Vaginal hysterectomy shortened the length of hospitalization significantly but did not affect the operative time. All of these differences was significant after adjusting for uterine weight (P <0.05). groups, except for uterine weight. Conclusions: For w omen with a uterus weighing 250 g or more, vaginal hysterectomy shortens the hospital stay without significantly increased perioperative morbidity when compared with the abdominal route.