Background: Vaginal hysterectomy is often associated with significant postoperative pain. This study aims to compare the analgesic efficacy and safety of dexmedetomidine versus fentanyl when used as an adjuvant to intrathecal bupivacaine in this setting. Methods: Bidar Institute of Medical Sciences conducted a randomised, double-blind clinical trial on 100 elective vaginal hysterectomy patients. Patients received intrathecal bupivacaine with dexmedetomidine (5 µg) or fentanyl (25 µg). Measurements included VAS pain levels, analgesia duration, and side effects. Results: The analgesic duration was substantially longer in the dexmedetomidine group (10.5 ± 1.5 hours) compared to the fentanyl group (8.0 ± 1.7 hours) (p<0.05 From 4 hours postoperatively, dexmedetomidine reduced pain scores at all times. Dexmedetomidine caused greater moderate hypotension and bradycardia but less vomiting and pruritus. Conclusion: Dexmedetomidine as an adjuvant to intrathecal bupivacaine offers superior postoperative pain control with fewer side effects compared to fentanyl in patients undergoing vaginal hysterectomy. Further studies are recommended to optimize dosing and assess long-term outcomes.