The current fashion for more conservative surgical alternatives in the management of menorrhagia — endometrial ablation using either the neodymium-yttrium-aluminium-garnet laser, 1 resectoscope 2 or radiofrequency heating 3 — may foster the illusion that hysterectomy is largely obsolete, outmoded or passé in managing menorrhagic patients. This is by no means the case, and advocates of minimally invasive therapy (I am one of them) must be careful not to treat endometrial ablation as a panacea for unacceptably heavy menstrual bleeding. This can only lead to the downfall of minimally invasive techniques. The treatment of totally inappropriate patients with endometrial ablation (such as those with dangerously large fibroids) leads to both unacceptable complication rates and poor results. The indications for, and contraindications to endometrial ablation are becoming clear as time passes and experience with these new techniques grows. At the same time it is apparent that there is a significant proportion of patients who do not respond well to such treatment and who are better managed with hysterectomy. In this article I intend to outline a relatively didactic management pathway for menorrhagic patients, and in doing so define the place of the ‘final cure’ — hysterectomy. I must emphasise that this is a personal view, albeit one that in general is held by many clinicians.