BACKGROUND Hysteroscopic endometrial resection is a minimally invasive alternative to hysterectomy for menorrhagia, with good short term results. However, in the long term about 20% of the patients undergo hysterectomy. Our results are presented and attention is drawn to the possible later development of pain. METHODS A total of 348 resections were done on 324 women, including 68 who also underwent resection of myoma. They were followed prospectively for one to eight years (mean 3.8). Further treatment (re-resection or hysterectomy) was offered to all those not satisfied. RESULTS Uterine perforation occurred in three cases (0.9%) (leading to one laparotomy), bleeding in 18 (5.2%), glycine overload in ten (2.9%), and infection in five (1.4%). During the follow-up, 63 (19.4%) have undergone hysterectomy, in 45 (67.2%) with pain as main or partial indication. At the end of the study period, 246 out of 260 (94.6%) were satisfied. CONCLUSIONS Hysteroscopic endometrial resection is a safe and effective treatment in women with menorrhagia, leading to about 80% of patients avoiding major surgery. In some women, pain develops de novo at some point after surgery and this may lead to hysterectomy. This pain may be atypical and difficult to diagnose as uterine in origin.