Purpose of Review <p>This report will review existing literature on vaginal hysterectomy (VH) safety, efficacy and cost-effectiveness. We aim to promote solutions to increase the achievability and adoption of the vaginal route for women undergoing hysterectomy.</p> Recent Findings <p>Rates of VH have continued to decline with the development of other minimally invasive hysterectomy approaches (most notably robotic). The evidence indicates that the costs and approach to hysterectomy are determined not by the surgical indications or patient characteristic but by the surgeon.</p> Summary <p>Use of the vaginal approach to hysterectomy is consistently recommended as the preferred approach where possible and it represents the highest value given equivalent or better clinical outcomes at the lowest cost. Despite these facts, rates of VH are low relative to other approaches stemming from training, marketing and surgeon-related factors that could be addressed. Techniques for approaching commonly cited reasons to not use VH are reviewed and strategies to promote greater use of this approach are presented.</p>