We aimed to identify the relationships between puerperal metritis (PM) and serum metabolites, uterine health, milk yield, and reproductive performance in dairy cows. Blood samples from 150 Holstein dairy cows were collected just after calving, and at 1, 2, and 4 weeks postpartum to measure serum concentrations of ${\beta}$-hydroxybutyrate (BHBA), urea nitrogen, total cholesterol (TCH), albumin, aspartate aminotransferase (AST), calcium, and magnesium. PM was diagnosed by the presence of fever (${\geq}39.5^{\circ}C$) and a watery, fetid uterine discharge during the first 14 days after calving. Cows were divided into two groups on the basis of the presence or absence of the disease: a control group (n = 83) and a PM group (n = 67). The cows diagnosed with PM were subcutaneously administered with 2.2 mg/kg ceftiofur for 3-5 days. The serum concentrations of BHBA tended to be higher (P = 0.06) and AST was higher (P < 0.05) in the PM group than in the control group 1 week after calving, whereas serum concentrations of urea nitrogen, TCH, albumin, calcium, and magnesium were lower (P < 0.05-0.0001) after calving in the PM group than in the control group. The probability of clinical endometritis was higher (odds ratio = 5.40, P < 0.001) in the PM group than in the control group. Moreover, the proportion of neutrophils in the uterus was also higher in the PM group than in the control group 4, 6, and 8 weeks after calving (P < 0.001). The mean milk yield 1 and 2 months after calving was lower (P = 0.05) in the PM group than in the control group. The hazard of pregnancy by 180 days after calving tended to be lower (hazard ratio = 0.60, P = 0.07) in the PM group than in the control group, which led to an extended mean interval between calving and pregnancy (19 days) in the PM group (P < 0.01). In conclusion, PM is associated with higher postpartum concentrations of BHBA and AST, and lower concentrations of urea nitrogen, TCH, albumin, calcium, and magnesium. Moreover, PM is associated with subsequent poor uterine health, lower milk yield, and poorer reproductive performance in dairy cows.