113. Brown Bleeding & Fertility: Could It Be Chronic Endometritis?

Could persistent brown bleeding or unexplained fertility struggles be more than “just old blood”? In this episode of Cycle Wisdom, Dr. Monica Minjeur uncovers the often-missed condition of chronic endometritis—a quiet, low-grade inflammation of the uterine lining that standard fertility workups frequently overlook. You’ll learn how to recognize key signs, why microbiome balance matters, and what diagnostic tools and treatments can restore uterine health, improve implantation, and boost fertility.

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Transcript

Monica: 0:02

Welcome back to Cycle Wisdom, where we empower women to restore natural menstrual cycles, to improve health and promote fertility. I'm your host, Dr. Monica Minjeur, and I'm so glad you're listening today. What if the reason fertility continues to be a problem or you have persistence of unusual brown bleeding is actually a quiet, chronic inflammation inside of your uterus that most standard workups miss. Today I'm going to be unpacking what chronic endometritis is, how we diagnose it accurately, and how a cycle focused plan can help restore a healthy uterine wall lining and your chances of pregnancy. So let's get started today with a story about a patient of mine who will call Tessa. Now Tessa came to see us as an elementary school teacher, and she knew that as her cycles changed throughout the school year, that there were going to be some ups and downs. However, over the course of the past year, she had noticed something new with her charting. She had identified that she was having some brown bleeding that was happening for the last two to three days at the very end of her cycle every single month. She also noticed what she described as a dull heaviness. That she noted in the middle part of her cycle every month. Her friends told her the brown bleeding was just old blood and she thought that it was normal. She saw her primary care doctor who had told her that bleeding can be normal as long as it's not lasting more than seven days. She was advised to just give it time, but she knew that something wasn't quite right because she had been working with one of our fertility awareness educators who told her that the brown bleeding needed to get evaluated. So at her first medical visit with me, we talked through her current symptoms and looked at her chart and the pattern jumped out. Very obviously, she had two to three days of consistent brown bleeding at the end of every menstrual cycle. Additionally, we were able to identify that she had shorter number of days in her luteal phase from the time she ovulated until her next cycle began, and she was also trying to conceive and had been unable to do so in the preceding seven to eight months. We discussed the possibility of a condition called chronic endometritis, which is something she had never heard of. Now we'll talk more about what that is, but basically it's an inflammation of the inner wall, of the uterine lining. So we discussed her options and chose to send a menstrual sample blood. For some additional testing. When we got those results back, we were able to identify that indeed she did have an overgrowth of bacteria, and we were recommended to try some targeted antibiotics that were based on those diagnostic results. In addition, we worked together to help restore her microbiome. By utilizing some probiotics, we continued to make sure that we were maintaining a good uterine wall lining by balancing her hormones. And we continued to keep an eye on what was happening with her charting patterns. Within the next month after treatment, her patterns of bleeding showed that the brown bleeding was actually gone. We continued to see improvement in her fertile mucus window and a steady ovulation pattern. Over the next few months, within three months, she was able to conceive naturally. She said to us, I kept being told that the brown bleeding was nothing, but it was the clue that changed everything. So what is chronic endometritis and why does it even matter? So chronic endometritis is different than endometriosis. So endometriosis, as we've talked about in the past, is deposits of uterine like tissue outside of the uterus. Whereas chronic endometritis is actual inflammation of the uterine wall lining or that endometrium. Now, in many cases, it is actually caused by a persistent low grade infection. Now, this can be normal bacteria that lives in the vaginal area or in the uterus that just gets a little bit imbalanced. Or it can be non-specific to bacterial infection and maybe a virus. Or a yeast, or maybe not anything infectious at all, and just persistent inflammation. How we identify this in practice is typically seeing brown bleeding that's lasting for two or more days, especially if it's happening in multiple cycles. In some women, this can actually show up as spotting that is lasting for much longer than expected. So generally we say anything beyond six to seven days. Or in some cases women will identify that they feel more of a pelvic pressure or fullness that's associated with their cycle, or sometimes at other times in their cycle, which can mean that inflammation is going on in the uterine wall lining. The other time we will often see it is in cases where women are trying to conceive or in cases of recurrent miscarriage, because if there's inflammation in the lining of the uterine wall, it makes an inhospitable area to allow implantation to occur. So why this matters and what we kind of pay attention to with this is that it's all about what we call the microbiome. So the microbiome is the good bacteria that make up all of the different areas of our body. Now, interestingly, in the female body, the uterus. The cervix and the vagina all have very distinct and different microbiomes, and so that's really important to understand that just because we have bacteria present, it doesn't mean that that's a bad thing. In fact, the uterus itself is not a completely sterile environment, and we rely on those good bacteria, crosstalk with the other bacteria in other areas as well as that environment in order to have a healthy immune system. So one of the most important bacteria that we have in the female genital tract is lactobacillus, and ideally, we're looking for lactobacillus to be the dominant bacteria and ideally greater than 90%. What we find is that in women that have a lactobacillus dominant microbiome, that's typically associated with a healthier lining of the uterine wall and better clinical outcomes. In fact, that lactobacillus means that it has more lactic acid, which decreases the pH, which means that there's fewer pathogens or bad bacteria that can set up shop. If we have a dysbiosis or an imbalance of that bacteria, it can be a part of the reason why we develop chronic endometritis, and again, can lead to all of these clinical symptoms as far as the brown bleeding, recurrent implantation failure, early miscarriage, and can actually be associated with fallopian tube obstruction because of the inflammation that can block off the first part of the tube. So what do we do if we suspect chronic endometritis? And what does this look like in the real world? So there's a couple of different ways that we can evaluate if we are suspicious that chronic endometritis may be playing a role with your brown bleeding. The first is that we can do microbiome testing. Now, there's a couple of different ways that we do this. One is through looking at direct menstrual sample blood. We can also do a vaginal sample or a vaginal swab. And in cases of fertility or in cases where you have a partner, we oftentimes will check a semen sample as well. The idea here is, is that we want to be looking for any bacteria, yeast, or viruses that could be causing an infectious component, and in some women, they actually are passing it back and forth from their partners. So it's important to do a thorough evaluation to determine if an infection is present. How do we know what is going on, and most importantly, how do we treat it? Another way that we can identify chronic endometritis is if you are undergoing a surgical procedure like a hysteroscopy, which is when they take a camera and actually look inside the uterus. Now you can actually see changes on a hysteroscopy that show inflammation or fluffy tissue, throughout the uterine wall. A biopsy is oftentimes taken when there's a hysteroscopy completed in order to evaluate for what we call plasma cells. Now there is a specific version of plasma cells we're looking for, but we want to take a look at, see if we have any of these CD 1 38 plasma cells present that that can indicate chronic endometritis. The other way that we can pick this up, as I mentioned, is on a biopsy. So some women will have just a general endometrial biopsy done, and we can look for these CD 1 38 plasma cells as well as culture. The tissue that's inside of the uterine wall lining. Now, interestingly enough, a culture alone can miss chronic endometritis in about half of the cases, and so we want to always take into consideration what is our clinical suspicion for having chronic endometritis in addition to those lab findings. In some rare cases when if we are unable to obtain any sort of testing or surgical or biopsy, we can propose treating blindly with antibiotics. Now, this is typically not the best recommendation, but in some cases, if you're unable to get a menstrual sample blood collection. Or if cost is prohibitive or you're unable to get to see a surgeon, we sometimes will treat with antibiotics and an an anti-inflammatory approach in order to see if we can help and improve that brown bleeding. It's not perfect, but in some cases it's the only option that we have. So what does treatment look like if we have identified, hey, we believe that chronic endometritis is here, or we've got this sample that's able to tell us, yes, this is exactly what's going on. So definitely if there is a specific bacteria or virus or yeast that's found, we want to treat with antibiotics, and in most cases, we want to treat with at least two to three weeks of antibiotics for women because we find better outcomes and better resolution of the symptoms. For men, we sometimes need to treat as long as four to six weeks because prostate secretions are very notorious for holding onto bacterial infections and can take a much longer treatment path. So again, depending upon what bacteria we find present, and if it was present in male or female form, we want to be able to determine who needs treatment. And oftentimes we want to treat both partners so that they don't continue to pass that infection back and forth. Another piece that's really important is, is in trying to decrease the inflammation that's going on. Again, infection can cause inflammation, but you can also have inflammation that is independent of any infection. So we focus our therapies here on low dose naltrexone, trying to help decrease inflammation. We also focus on an anti-inflammatory diet, so avoiding gluten, sugar and dairy, and then also always paying attention to a healthy gut microbiome. In addition to trying to decrease the inflammation that may be going on with our gut, we also want to restore good bacteria. So again, going back to those probiotics of lactobacillus, and we can take lactobacillus by mouth or vaginally in order to help promote a good endometrial ecosystem for that microbiome. Most importantly, we want to make sure that we have successfully treated and cured that chronic endometritis. So one of the nice things about tracking chronic endometritis is that we can see on your charting if that brown bleeding has resolved. We are fairly confident that the endometritis has at least improved, if not gone away completely. In some cases, we do recommend repeating that hysteroscopy to check and evaluate and make sure all of the visual changes have occurred or repeating a biopsy. In order to make sure that the plasma cells are gone, many women notice a fairly quick resolution of their other symptoms in addition to the brown bleeding being gone. But unfortunately, chronic endometritis can be recurrent and can be difficult to treat. So it's important to be diligent about this and make sure that we're treating everything that we can. So what can you do right now if you've had recurrent miscarriages? If you're having difficulties conceiving, and especially if you're noticing a persistence of brown bleeding, you want to start asking about the possibility of chronic endometritis as playing a role in your symptoms. Ask your healthcare professional, can we evaluate further this brown bleeding that I'm seeing with my charting? And if you're told that it's just normal and everybody has it, don't accept that for an answer, especially if you're seeing that for more than two or three days every cycle. If you can get a diagnosis of chronic endometritis, make sure you clarify the plan. What are the antibiotics that are needed in order to treat the infection? If it's present? How long do I need to be on treatment? Should my partner get treated? And also, what does repeat evaluation look like? Ask whether or not probiotics are appropriate for you. In most cases, they are, especially if you're going to be treated with antibiotics. We don't wanna completely wipe out your good gut and vaginal bacterial strains. So make sure that you're utilizing probiotics in order to help restore that healthy microbiome. And most importantly, make sure that you are repeating evaluation. And continuing to balance the hormone levels because if hormone levels are not balanced well throughout this cycle, you are going to have a hard time with maintaining a good, healthy uterine wall lining. Imagine if a thoughtful evaluation uncovered why you are seeing irregular brown bleeding. Imagine that targeted treatment can steadily improve it and improve the good overall microbiome of what's going on in the uterine wall lining. Your bleeding pattern can become more clear, ovulation, easier to identify, and you can see progress that is measurable on your charts and your labs. Step by step, your uterus becomes a more supportive environment in order to help improve your health and promote fertility. If you're ready to work with our elite team of healthcare professionals, go to our website, radiant clinic.com to schedule a free discovery call and learn more about our package based pricing for comprehensive care. We are currently able to see people for in-person appointments in our Cedar Rapids, Iowa Clinic, or can arrange for a telehealth visit if you live in many different states across the us. Check out our website for current states that we can serve medical clients and let us know if your state is not listed to see if we can still cover you there as we are constantly expanding our reach. Please note that our fertility educators are able to take care of clients no matter where they live. Thank you so much for listening to this episode. Please share this podcast with someone in your life who would benefit from our services. Remember to subscribe to this podcast for more empowering content that I look forward to sharing with you on our next episode of Cycle Wisdom.