Rise of Hormonal Endometritis: A Silent Cause of Recurrent Miscarriage in Indian Women - Dr Sindura Ganga R

Recurrent miscarriage is a profoundly painful experience for couples — and for clinicians who try to find answers. Traditionally, we look for chromosomal problems, uterine abnormalities, infections and clotting disorders.

Lately, however, an understated and under-recognised problem has been appearing more often in practice: a low-grade inflammation of the endometrium driven by subtle hormonal and immune shifts.

I describe it here as hormonal endometritis — not the classic acute infection you can see on culture, but a smouldering endometrial response that can interfere with implantation and early pregnancy maintenance.

What I am seeing in clinic

Many of these women do not have fever, heavy discharge or classic pelvic infection signs. Instead they report repetitive early losses, mild menstrual irregularities, or subtle premenstrual pelvic discomfort. Often they are otherwise healthy, in their late twenties or thirties, and may have normal ultrasound scans.

What sets their stories apart is a pattern of inconsistent cycles, history of irregular ovulation, or prior exposure to endocrine stressors — weight change, recent prolonged stress, or unrecognised thyroid dysfunction.

On endometrial sampling, instead of frank infection, we find evidence of chronic inflammation: plasma cells, stromal changes and immune cell infiltration that suggest the lining is not receptive.

How hormones and immunity interact

The endometrium is exquisitely sensitive to hormonal cues. Estrogen primes the lining; progesterone transforms it into a supportive bed for the embryo. If these signals are off — for example, with luteal phase deficiency, anovulatory cycles, or fluctuating progesterone — the lining can remain in a pro-inflammatory state.

At the same time, small shifts in immune balance — an overactive local innate response or altered regulatory T-cell activity — prevent the immune tolerance required for an implanting embryo. In short, a hormonal wobble can feed a localized immune reaction and create a hostile microenvironment even when blood tests and scans look reassuring.

Why this pattern may be rising now

Several factors common in India may contribute. Lifestyle changes that affect weight and metabolic health, earlier return to high-stress work after childbirth, and increasing exposure to environmental endocrine disruptors are all suspects.

Additionally, better access to early pregnancy loss evaluation means we now see cases we might have missed earlier. That doesn’t mean every recurrent miscarriage is due to hormonal endometritis — but it is a cause we should actively consider.

Diagnosing the problem

Diagnosis requires suspicion. Simple blood tests alone often miss the issue. A careful menstrual history, ovulation tracking and targeted hormonal assays (mid-luteal progesterone, thyroid function, glucose metabolism) are the first step.

If miscarriage recurs, an endometrial biopsy timed in the luteal phase can reveal microscopic inflammation. Newer tests that profile immune cell populations or cytokine patterns in the endometrium can be helpful in specialised centres, although they are not yet routine everywhere.

Treatment and practical steps

Treatment combines correcting hormonal abnormalities and calming the endometrial immune response. If ovulatory dysfunction or luteal insufficiency is present, targeted progesterone support across the luteal phase (or tailored ovulation induction) restores the hormonal milieu.

Where chronic endometrial inflammation is documented, a short course of targeted antibiotics may be used if a pathogen is identified, but more often we use anti-inflammatory strategies: low-dose corticosteroid protocols in carefully selected cases, or intrauterine device removal when indicated.

Addressing metabolic issues — weight optimisation, treating insulin resistance, and restoring thyroid balance — is equally important.

Lifestyle measures matter: stable sleep, stress reduction, modest exercise and a balanced diet that avoids rapid weight swings all help hormonal stability. Women trying to conceive should avoid unproven supplements that claim immune-modulation unless recommended by their physician.

A cautious but hopeful message

Hormonal endometritis is not an easy label — it sits at the intersection of endocrinology and reproductive immunology. But recognising it matters because it changes our approach: we stop searching only for obvious infections or structural problems and start restoring the hormonal and immune environment that supports implantation.

Many women treated with a focused, multidisciplinary plan go on to have successful pregnancies.

If you have faced two or more unexplained early losses, ask your clinician about a targeted evaluation that includes careful cycle assessment and, if appropriate, an endometrial biopsy in the luteal phase.

Recurrent miscarriage is heartbreaking, but with attentive investigation and tailored care, we can find causes that were once hidden and give couples a better chance at a healthy pregnancy.

Disclaimer: The views expressed in this article are of the author and not of Health Dialogues. The Editorial/Content team of Health Dialogues has not contributed to the writing/editing/packaging of this article.