The Effects of Hormonal and Non-Hormonal Intrauterine Devices on Female Sexual Function: A Systematic Review

Abstract

Objectives

The goal of this paper was to review and synthesize the extant literature exploring the impact, if any, of copper (Cu) and levonorgestrel (LNG) intrauterine devices on female sexual function.

Methods

To review the literature, Medline, PubMed, and PsychINFO, were searched for primary research articles that were available in English and measured female sexual function in Cu- and LNG-IUD users. 35 quantitative and 2 qualitative research papers met criteria for inclusion in this systematic review. The 35 quantitative articles were then rated based on the STROBE statement.

Results

The included articles indicated a positive impact of LNG-IUDs on sexual pain, and a positive-to-neutral effect of IUDs on sexual desire, however more research is warranted. This review also found IUDs to be generally non-impactful on other domains of sexual function, including arousal, lubrication, orgasm, satisfaction, and overall sexual function.

Conclusions

As this review highlights that LNG-IUDs may improve sexual pain, future research should explore this connection further. Additional RCTs should also be conducted to confirm effects on sexual function with little bias. A better understanding of the impact of both Cu- and LNG-IUDs is necessary to expand upon this field of research and uncover any other benefits or detriments from IUDs.

Introduction

Intrauterine devices (IUDs) are commonly used, safe, and effective long-acting reversible contraceptives (LARCs). LARCs are the third most common contraceptive method group among U.S. women, followed by female sterilization and oral contraceptive pills (Daniels & Abma, 2018). IUDs are offered in two forms: hormonal and non-hormonal. The hormonal IUD delivers levonorgestrel (LNG), a form of progesterone, that suppresses endometrial proliferation and thickens the cervical mucus, therefore preventing pregnancy (Ortiz & Croxatto, 2007). In comparison, the non-hormonal IUD works by releasing copper (Cu) ions into the uterus, which alters the uterine lining and fallopian tubes, making it inhospitable to sperm (Ortiz & Croxatto, 2007). Both LNG- and Cu-IUDs are more than 99% effective at preventing pregnancy and can remain in use for 5 (LNG-) to 10 (Cu-) years, making them an increasingly popular option for family planning. However, if either IUD were expelled from the uterus or not placed correctly by a healthcare professional, it can fail at preventing pregnancy (Thonneau et al., 2006).

Much of the research examining the side effects of hormonal and non-hormonal IUDs has surrounded contraceptive efficacy and the impact of IUDs on menstrual and pelvic health. Research has demonstrated that LNG-IUDs improve symptoms of menorrhagia (Pakarinen & Luukkainen, 2007), endometrial hyperplasia (Behnamfar et al., 2014), endometriosis (Lan et al., 2013), and adenomyosis (Chen et al., 2020). LNG-IUDs have also been found to reduce the risk of pelvic infection (Toivonen, 1993) and ovarian cancer (Balayla et al., 2021). Given the suppression of endometrial proliferation induced by LNG-IUDs, reduced menstrual bleeding and, for some women, induced amenorrhea with continued use has been reported (Cameron, 2001). Conversely, Cu-IUDs have been shown to increase menstrual bleeding, cramps, and intermenstrual spotting (Hubacher et al., 2009).

In comparison to the well-documented impact of IUDs on menstrual and pelvic health, little is known about the impact of IUDs on women’s sexual function. It is possible that IUDs may improve sexual function through multiple pathways. For example, using IUDs may reduce fears of pregnancy and therefore increase sexual function among users. Indeed, research by Graham et al. (2004) indicated that fears of unwanted pregnancy have a large, negative impact on sexual arousal. Therefore, using a highly-effective birth control method, such as an IUD, may reduce pregnancy fears and enhance sexual function. Additionally, as researchers have demonstrated a positive correlation between contraceptive use and sexual communication (Widman et al., 2006), using an IUD could increase a couple’s sexual communication and, consequently, improve their sexual function.

It is also possible that LNG-IUDs improve sexual function via decreases in symptoms of gynecologic disorders, such as endometriosis (Tanmahasamut et al., 2012). Jia et al. (2013) found that, among women with endometriosis, those with no to mild pelvic pain had a lower risk of sexual dysfunction than those with moderate to severe pelvic pain. To a similar effect, Ferrero et al. (2005) compared dyspareunia and sexual satisfaction scores among three groups of women: women with deep infiltrating endometriosis, which tends to come with greater and more severe symptoms; women with peritoneal endometriosis, which often has fewer and less severe symptoms; and women without endometriosis. They discovered that women with milder, peritoneal endometriosis and women without endometriosis reported less dyspareunia and better sexual satisfaction than women with deep infiltrating endometriosis. Given that LNG-IUDs reduce endometriosis symptoms, and women with fewer and milder symptoms report better sexual satisfaction as well as less genital/pelvic pain, LNG-IUDs may improve sexual function among women with endometriosis. Possible benefits to sexual function could also extend to other gynecologic disorders with similar symptomatology.

It is also possible that IUDs may negatively impact female sexual function. Hormones are integral to the physiology of sexual function, and altering local hormone levels may impact genital tissue or other physiologically-based components of sexual function (e.g., lubrication). As the progestins found within LNG-IUDs thin the endometrium (Jones & Critchley, 2000), it is possible that other biological systems in the genital tract are also impacted. For example, Moncla et al. (2016) discovered that cervical and vaginal fluid glycomes in the genital tract can respond to internal, biological signals such as hormones and vaginal microflora. In addition, Cu-IUDs can increase menstrual bleeding and cause irregular bleeding patterns among users (Hubacher et al., 2009). These menstrual side effects may negatively impact sexual function, specifically desire, as research has shown that women using non-hormonal contraceptives (NHCs) report decreases in desire during bleeding days (Elaut et al., 2016).

The American College of Gynecology (ACOG) states that both Cu- and LNG-IUDs are safe and effective birth control options for women seeking to prevent pregnancy (Espey & Hofler, 2017). In addition, recent reviews from the field of female contraception have maintained the high efficacy and safety of LARC methods (Moray et al., 2021; Zgliczynska et al., 2020), as well as highlighted the importance of appropriate contraceptive counseling (Fox et al., 2018; Zapata et al., 2018). This present review adds to the literature as it explores possible effects of IUDs on female sexual function and allows for the comparison between the Cu- and LNG-IUDs to better understand potential differences between hormonal and non-hormonal forms of contraception.

The aim of the present systematic review is to synthesize the literature on the impact of IUDs on female sexual function. Summarizing these data in such a way will allow for the development of a comprehensive understanding of how Cu- and LNG-IUDs affect female sexual function, and identify areas in need of greater research.

Methods

The PRISMA statement was used as a guide to conducting this systematic review (Moher et al., 2009). An extensive search was conducted using three research databases (PubMed, PsychINFO, and MEDLine) for papers measuring sexual function in women using hormonal and non-hormonal intrauterine devices. For the purpose of this review, sexual function was assessed based on the six domains of the Female Sexual Function Index (FSFI; Rosen et al., 2000), which is considered the gold standard in assessing sexual function in women (Sand et al., 2009; Stephenson et al., 2016). These domains are: desire, arousal, lubrication, orgasm, satisfaction, and pain. The keywords “sexual desire,” “sexual arousal,” “lubrication,” “orgasm,” “sexual satisfaction,” “sexual pain,” and “sexual function” were used in combination with “intrauterine device” to collect appropriate studies from each of the three databases. Papers published until May 2020, which is when this search was conducted, were included in this review. No date range was specified when searching for research studies.

Search results were compiled (N = 595) and 5 studies analyzing sexual function in IUDs were found as a result of reviewing study references and added to the pool (N = 600). Duplicates were removed, which led to a total of 396 possible articles. Titles and abstracts of these studies were reviewed and 283 were removed. The full papers of the remaining studies (N = 113) were reviewed and 76 were removed. This resulted in a total of 37 remaining studies included in this systematic review. Studies were deemed eligible to be included in this review if they were (a) published in peer-reviewed journals, (b) available in English, (c) presented original findings (not a review or editorial), (d) included IUD (LNG- and Cu-) users and (e) measured potential effects on sexual function or other sexual side effects (i.e. frequency of sexual activity). See Figure 1 for an illustration of the search process.

Figure 1.

PRISMA flow diagram of studies included in systematic review.

The two authors independently rated the 35 quantitative studies based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement, a well-established guideline for grading observational studies. The STROBE statement is comprised of 22 items and assesses study components such as design, bias, and analyses. To ensure reliability of the STROBE assessment scores, both authors compared and discussed their independently rated scores and agreed upon uniform ratings for each study when discrepancies arose. The total STROBE scores were also rated to represent paper quality, high quality = 17–22, moderate quality = 11–16, and low quality = 0–10. The STROBE was not applicable to the 2 qualitative studies and thus were not evaluated using the STROBE statement. See Table 1 for sexual function domains assessed in each study as well as results from the STROBE assessments.

Table 1.

Summary of Overall Results for all Studies Exploring Hormonal and NON-Hormonal IUD Sexual Side Effects.

Reference	Desire	Arousal	Lubrication	Orgasm	Satisfaction	Pain	Overall Function	Other Effects	Quality of Evidence	Score
Arlıer et al. 2017							X		Moderate	15
Baldaszti et al., 2003	X							X	Moderate	12
Bastianelli et al., 2011	X	X	X	X	X	X	X		Moderate	17
Boozalis et al., 2016	X								High	18
Bryant et al., 2015								X	–	–
Caruso et al., 2018	X	X	X	X	X	X	X	X	High	18
Chen & Ho, 1999								X	Moderate	14
Chen et al., 1998						X		X	Moderate	16
Cozza et al., 2017	X		X			X			Moderate	15
Enzlin et al., 2012	X	X		X	X		X	X	Moderate	15
Fataneh et al., 2013	X	X	X	X	X	X	X		High	18
Ferreira et al., 2019							X		Moderate	17
Gorgen et al., 2009	X					X			Moderate	13
Halmesmäki et al. 2007					X		X		High	19
Hassanin et al., 2018	X	X	X	X	X	X	X		Moderate	17
Herzberg et al., 1971	X								Low	9
Higgins et al., 2015								X	–	–
Higgins et al., 2016							X		High	18
Hurskainen et al., 2004					X		X		High	20
Jacobson et al. 2019						X			Moderate	14
Koseoglu et al., 2016	X	X	X	X	X	X	X		Moderate	13
Li et al., 2004	X				X				High	19
Malmborg et al., 2016	X					X			High	18
Malmborg et al., 2019a	X			X	X				High	19
Martin-Loeches et al., 2003	X								Moderate	16
Neri et al. 2018							X		Moderate	11
Oddens, 1999	X							X	Moderate	12
Panchalee et al., 2014							X		Moderate	17
Eterkin Pinar et al. 2019							X		Moderate	17
Sakinci et al. 2016	X	X	X	X	X	X	X		High	19
Sanders et al., 2018								X	High	18
Sharma, 1972	X							X	Low	8
Skrzypulec & Drosdzol, 2008	X	X	X	X	X	X	X		Moderate	17
Suhonen et al. 2004	X				X			X	Moderate	12
den Tonkelaar & Oddens, 2001b								X	Moderate	15
Toorzani et al., 2010					X				Moderate	12
Umran & Melike, 2016	X	X	X	X	X	X	X		Moderate	16

Note. STROBE assessment not applicable to qualitative studies.

^a101 Cu-IUD and 47 LNG-IUD users also participated in Malmborg et al., 2016; ^b1303 OCP, 966 condom, 42 IUD, 428 NFP, and 139 sterilization users also participated in Oddens, 1999.

Both authors extracted data from all eligible studies and summarized them in an electronic form which included the following items: name of author, year of publication, country, age, sample size, contraceptive method, study design, follow-up duration, and outcomes. The principal summary measures were differences of means, risk ratios, confidence intervals, and raw counts of discontinuations and complaints. Data on study design, population, instrument, and findings from the 37 studies can be found in Supplemental Tables 1–8.

Results

Desire

Twenty-one articles studied the effects of IUDs on sexual desire, seven were deemed high quality, twelve were deemed moderate quality, and two were deemed low quality. Of these twenty-one studies, eight reported neutral effects (Boozalis et al., 2016; Enzlin et al., 2012; Koseoglu et al., 2016; Li et al., 2004; Martin-Loeches et al., 2003; Sakinci et al., 2016; Sharma, 1972; Suhonen et al., 2004). One study (Suhonen et al., 2004) measured sexual desire in women using either a LNG-IUD (n = 94) or using OCPs (n = 99) and found no significant changes in sexual desire from before to 12 months after initiating the contraceptive regimen. Similarly, no significant between group-differences were reported by Enzlin et al. (2012), Boozalis et al. (2016), Koseoglu et al. (2016), and Sakinci et al. (2016).

When comparing multiple types of IUDs to other contraceptive methods, Li et al. (2004) measured no significant changes in desire among the IUD, injectables, and OCP groups, however, they did measure an increase in desire among the sterilization group. Similarly, Sharma (1972) measured sexual desire in 71 Indian women beginning use of an IUD and found that 5.6% reported increased desire, 36.1% reported decreased desire, and 58.3% reported no change in desire 6 months after insertion. Martin-Loeches et al. (2003) reported no significant differences among Spanish women using multiple types of IUDs and OCPs. Notably, though, they did observe reductions in sexual desire by 12.1% in IUD users and 10.4% in OCP users.

On the other hand, Herzberg et al. (1971) found a continuous increase in mean libido scores among the IUD group, with only a small change and no sign of continuous improvement for the OCP group over the course of eleven months. It is important to note that libido was assessed as a composition of sexual satisfaction, interest, and frequency of intercourse. In this study, no IUD was removed due to the loss of libido, however, 17 women stopped using OCPs for that reason. In addition, Oddens (1999) found that past IUD users reported decreased desire more often than current IUD users. Research has also demonstrated greater levels of desire among Cu-IUD users (Hassanin et al., 2018; Malmborg et al., 2016) and LNG-IUD users (Caruso et al., 2018; Skrzypulec & Drosdzol, 2008) when compared to users of other contraceptive methods. To a similar effect, LNG-IUD users reported an overall improvement in sexual desire from 0- to 12-months post-insertion (Bastianelli et al., 2011). Baldaszti et al. (2003) found that among 165 LNG-IUD users, 16 women removed their IUD prematurely, two of whom did so due to reduced libido.

In a group of women treated for abnormal uterine bleeding with either an abdominal hysterectomy or a LNG-IUD, 5/30 IUD users and 9/30 hysterectomy patients reported decreased libido after six months (Cozza et al., 2017). They also found that 20% of IUD users and 30% of hysterectomy patients had low sexual desire. Malmborg et al. (2019) compared LNG-IUD and Cu-IUD users and found that both groups reported a negative effect on sexual desire. IUD users have also reported worse sexual desire when compared to women using condoms, withdrawal, and OCPs (Fataneh et al., 2013; Umran & Melike, 2016). As such, hormonal and non-hormonal IUDs may affect female sexual desire.

Arousal

Nine articles in this review studied the effects of IUDs on female sexual arousal. Three of these studies were considered high quality and six were considered moderate quality. Four of the studies indicated no significant effects on sexual arousal (Bastianelli et al., 2011; Enzlin et al., 2012; Koseoglu et al., 2016; Umran & Melike, 2016). Indeed, Umran and Melike (2016) found no differences in arousal among Turkish women with various IUDs (n = 87), tubal ligation (n = 21), using oral contraceptive pills (n = 49), withdrawal method (n = 235), or condoms (n = 87; c.f. Fataneh et al., 2013). There do not appear to be any meaningful between-group differences among Cu- IUD users and women using no contraceptives (Koseoglu et al., 2016; but see also Sakinci et al., 2016). Several additional studies supported these findings (Bastianelli et al., 2011; Enzlin et al., 2012; Hassanin et al., 2018).

Conversely, Caruso et al. (2018) found improvements in arousal six months after insertion among LNG-IUD users who recently underwent elective abortion, yet no significant changes emerged for women beginning the use of contraceptives (patches, pills, or rings) after elective abortion. Furthermore, one study (Skrzypulec & Drosdzol, 2008) reported significantly better arousal among women using the LNG-IUD compared to women using another IUD or no form of contraceptive. Though three studies reported positive effects (Caruso et al., 2018; Hassanin et al., 2018; Skrzypulec & Drosdzol, 2008) and two reported negative effects (Fataneh et al., 2013; Sakinci et al., 2016), the majority of the studies reported neutral effects on arousal. As a result, it appears that IUDs may not meaningfully affect sexual arousal.

Lubrication

Nine studies measured the effects of IUDs on vaginal lubrication. Three articles were assessed as being high quality and six articles were assessed as being moderate quality. Of these nine studies, four noted no significant between-group differences in lubrication (Bastianelli et al., 2011; Koseoglu et al., 2016; Skrzypulec & Drosdzol, 2008; Umran & Melike, 2016). For example, two studies found no notable differences in lubrication between women with a Cu-IUD (Koseoglu et al., 2016) or LNG-IUD (Skrzypulec & Drosdzol, 2008) and women not using contraceptives, though poorer lubrication in IUD users has been noted elsewhere (Fataneh et al., 2013; Sakinci et al., 2016). A large study by Hassanin et al. (2018) partially supported neutral effects of IUDs with results indicating no significant differences in FSFI lubrication scores between Egyptian women with Cu-IUDs (n = 45) and women not using contraceptives (n = 100). However, they did report better lubrication in Cu-IUD users (n = 45) than in women using progestin injectables (n = 22), combined oral pills (n = 21), or progestin-only pills (n = 19).

Notable effects were found in two clinically distinct populations. Caruso et al. (2018) examined the impact of LNG-IUD at 6- and 12-months post-insertion in a sample of women who recently underwent elective abortion. In this study, significant, positive effects were found at six months and were maintained at twelve months. In a group of 60 women with abnormal uterine bleeding, half were treated with LNG-IUD, and half were treated with an abdominal hysterectomy (Cozza et al., 2017). It was found that 6/30 IUD users and 8/30 hysterectomy patients experienced vaginal dryness. However, these effects were not replicated in a similar study conducted in a more general population of women (Bastianelli et al., 2011). Therefore, in general, it does not appear as though Cu-IUDs and LNG-IUDs have a significant impact on vaginal lubrication.

Orgasm

Ten articles in this review examined the effects of IUDs on orgasm. Of these ten articles, four were scored as high quality and six were scored as moderate quality. Half of the studies reported no impact on orgasm (Bastianelli et al., 2011; Enzlin et al., 2012; Koseoglu et al., 2016; Malmborg et al., 2019; Umran & Melike, 2016). For example, no significant differences in orgasm were found between Cu-UD users and women using no contraceptives (Hassanin et al., 2018; Koseoglu et al., 2016) or LNG-IUDs (Enzlin et al., 2012; Malmborg et al., 2019). There also does not appear to be any change in orgasm function in LNG-IUD users from pre- to 12-months post-insertion (Bastianelli et al., 2011).

On the other hand, improvements in orgasm have been noted 6-months post-insertion among LNG-IUD users (Caruso et al., 2018), in LNG-IUD users compared to Cu-IUD or no contraceptives (Skrzypulec & Drosdzol, 2008), and in Cu-IUD users compared to women using OCPs or injectables (Hassanin et al., 2018). Worse orgasm scores were noted in Cu-IUD users than in women using no form of contraceptives (Sakinci et al., 2016), as well as in general IUD users than in women using OCP, condoms, and natural family planning (Fataneh et al., 2013). Overall, however, there appears to be greater evidence suggesting IUDs may not have large impacts on orgasm.

Satisfaction

Fifteen articles in this review measured the effects of IUDs on sexual satisfaction. For these fifteen papers, seven were considered high quality and eight were considered moderate quality. Nine studies reported neutral effects (Bastianelli et al., 2011; Halmesmäki et al., 2007; Hurskainen et al., 2004; Koseoglu et al., 2016; Li et al., 2004; Sakinci et al., 2016; Suhonen et al., 2004; Toorzani et al., 2010; Umran & Melike, 2016). No significant between-group differences were found among women using various IUDs compared to those using condoms, OCPs, withdrawal methods, and tubal sterilization ( Toorzani et al., 2010; Umran & Melike, 2016; c.f. Fataneh et al., 2013 ). No notable differences in sexual satisfaction were found between Cu-IUD users and women using no form of contraceptives (Koseoglu et al., 2016; Sakinci et al., 2016). Li et al. (2004) found no significant differences in sexual satisfaction among Hong Kong Chinese women before and three to four months after insertion of an IUD (Cu- or LNG-IUDs; n = 96), and initiation of OCPs (n = 87), and injectables (n = 67). However, they did find significant improvement after three to four months in women who had undergone female sterilization (n = 111). Among women treated for menorrhagia with either a hysterectomy or LNG-IUD, no significant change in satisfaction was noted in the LNG-IUD group from pre-insertion to 5-years post-insertion, though, there was an increase in satisfaction in the hysterectomy group in the same time frame (Halmesmäki et al., 2007). No changes in satisfaction were also noted from 0- to 12-months of continuous use in LNG-IUD and OCP users (Bastianelli et al., 2011; Suhonen et al., 2004).

However, in women who had recently undergone elective abortion, Caruso et al. (2018) noted improvements in satisfaction between 0- and 6-months post-insertion of the LNG-IUD with no change for the OCP, patch, and vaginal contraceptives group over the same period of time. Similarly, Skrzypulec and Drosdzol (2008) reported enhanced satisfaction in LNG-IUD users compared to other IUD users and women using no contraceptives. On the other hand, Cu-IUDs may facilitate greater satisfaction than LNG-IUDs (Malmborg et al., 2016), injectables, OCPs, and no contraceptives (Hassanin et al., 2018). As such, IUDs might have a neutral to positive effect on women’s sexual satisfaction.

Pain

There were thirteen articles in this review that studied the effects of IUDs on sexual pain. Four of which were deemed high quality and nine of which were deemed moderate quality. Six of these demonstrated positive effects (Bastianelli et al., 2011; Caruso et al., 2018; Chen et al., 1998; Cozza et al., 2017; Gorgen et al., 2009; Skrzypulec & Drosdzol, 2008). One study (Cozza et al., 2017) measured sexual pain in 60 women treated for abnormal uterine bleeding with either a LNG-IUD (n = 30) or an abdominal hysterectomy (n = 30). Six months after treatment, pain was found to decrease by 75.3% in LNG-IUD users, and only 3/30 of IUD users and 4/30 of hysterectomy patients reported dyspareunia as a side effect. Similar reports of improvements in pain have been reported in populations of Turkish women treated with LNG-IUD for menorrhagia (Gorgen et al., 2009), women receiving the LNG-IUD (Bastianelli et al., 2011), and women receiving the LNG-IUD following elective abortion (Caruso et al., 2018). This effect appears to be unique to the LNG-IUD (Chen et al., 1998; Skrzypulec & Drosdzol, 2008).

Four other studies reported no significant between-group differences among Cu-IUD users and women using no form of contraceptives (Koseoglu et al., 2016; c.f. Sakinci et al., 2016), Cu-IUD users, OCPs, injectables, and women using no contraceptives (Hassanin et al., 2018), and women using various IUDs and contraceptive methods (Fataneh et al., 2013; Umran & Melike, 2016). However, Malmborg et al. (2016) found that women using hormonal contraceptive methods reported more pain than women using non-hormonal methods. Though four studies reported no significant effects (Fataneh et al., 2013; Hassanin et al., 2018; Koseoglu et al., 2016; Umran & Melike, 2016) and three reported negative effects (Jacobson et al., 2019; Malmborg et al., 2016; Sakinci et al., 2016), many of the studies reported positive effects on pain, particularly following insertion of the LNG-IUD.

Overall function

Seventeen articles in this review examined the effects of IUDs on overall sexual function. Of these seventeen papers, six were assessed as high quality and eleven were assessed as moderate quality. The majority (11 out of 17) of studies reported no significant between-group differences in overall function (Bastianelli et al., 2011; Enzlin et al., 2012; Ertekin Pinar et al., 2019; Ferreira et al., 2019; Halmesmäki et al., 2007; Higgins et al., 2016; Hurskainen et al., 2004; Koseoglu et al., 2016; Neri et al., 2018; Panchalee et al., 2014; Umran & Melike, 2016). In fact, Ertekin Pinar et al. (2019) found no significant differences in sexual function among women using various IUDs compared to those using condoms, pills, injections, implants, and withdrawal methods (Umran & Melike, 2016; but see also Fataneh et al. (2013). No meaningful differences were found between Cu-IUD users and women using no contraceptives (Koseoglu et al., 2016; c.f. Sakinci et al., 2016), among women using three variants of the Cu-IUD (Panchalee et al., 2014), or between Cu- and LNG-IUD users (Ferreira et al., 2019). A lack of differences have also been noted among Cu-IUD, LNG-IUD (Enzlin et al., 2012) and implant users (Higgins et al., 2016). Notably, the only RCT included in this review (Hurskainen et al., 2004) found no significant between-group differences in sexual problems among women treated for menorrhagia with either a hysterectomy or LNG-IUD. Hurskainen et al. (2004) also reported no changes in sexual problems in either group over the following five years. Likewise, other studies have found no changes in sexual function among LNG-IUD users up to a year post-insertion (Bastianelli et al., 2011; Neri et al., 2018).

By contrast, Caruso et al. (2018) found improvements in sexual function in women with LNG-IUDs, OCPs, patch, and vaginal contraceptives from pre to six and six to twelve months of continuous use after elective abortion. Though improvements were found in all contraceptive groups, women using the LNG-IUD experienced the greatest gains in overall sexual function. This group of women was also the only group whose scores on the FSFI moved from the sexual dysfunction to functional range. Similar findings were reported by Arlıer et al. (2017) who found a significant increase in sexual function from pre- to 6-months and pre- to 12-months post-insertion in LNG-IUD users. In addition to these longitudinal findings, cross-sectional research has also noted positive effects on overall sexual function. Such effects have, for example, been noted among LNG-IUD users when compared to women using another IUD or no contraceptives (Skrzypulec & Drosdzol, 2008), and Cu-IUD users when compared to women using OCPs, injectables, and no contraceptives (Hassanin et al., 2018). Taken together, findings from these studies suggest that IUDs may not impair overall sexual function.

Other effects

Twelve articles in this review explored other effects of IUDs on sexual function. Of the ten quantitative papers reporting on other sexual side effects, two were considered high quality, seven were considered moderate quality, and one was considered low quality. Six of these twelve studies reported on frequency of sexual activity (Chen et al., 1998; Chen & Ho, 1999; Enzlin et al., 2012; Oddens, 1999; Sharma, 1972; Suhonen et al., 2004). Half of these studies found no significant between-group differences (Chen et al., 1998; Enzlin et al., 2012) or changes over time (Suhonen et al., 2004). Two out of twelve studies examined whether IUDs may impede or disturb users during sexual intercourse (Baldaszti et al., 2003; Bryant et al., 2015). Though Bryant et al. (2015) reported that one of the most common rumors about IUDs is that they impede sexual intercourse, other research has found that most women (86%; 142 out of 165 users) reported that their IUD did not bother them during sexual intercourse (Baldaszti et al., 2003).

In another qualitative study, Higgins et al. (2015) found that among participants with a history of using any contraceptive method, most reported positive sexual aspects of using an IUD. Similarly, in a large study on multiple contraceptive methods, current IUD users reported greater sexual intercourse frequency, pleasure, spontaneity, and positive influence on sex life than past IUD users (Oddens, 1999). Caruso et al. (2018) found that LNG-IUD and SARC users reported significant reductions in sexual distress over 12 months post-abortion.

Across implant, Cu-IUD, and LNG-IUD users, women who perceived negative sexual side effects were more likely to discontinue their respective contraceptive method than women who perceived no effects or positive effects on sexuality (Sanders et al., 2018). Likewise, den Tonkelaar and Oddens (2001) found that IUD users who were dissatisfied with their method, reported higher rates of negative and no changes in sex life, and lower rates of positive changes in sex life than IUD users who were satisfied with their method. Overall, while some women report dissatisfaction with IUDs, many women report little to no negative impact.

Discussion

The field of contraceptive research has been slow to provide a comprehensive understanding of how different contraceptive methods may impact women’s sexual function. Research in this area has principally and understandably surrounded the efficacy and acceptability of female contraceptives, with few studies examining possible effects on sexual function. However, this knowledge is crucial for advancing our understanding of women’s sexual health and well-being. As such, the aim of the present systematic review was to synthesize the extant literature surrounding the possible impacts of IUDs on women’s sexual function.

The most consistent finding identified in this review is that IUD use appears to improve sexual pain. Notably, all of the longitudinal studies that explored the effects of IUDs on sexual pain reported positive effects, and all were deemed moderate or high quality. One such study (Caruso et al., 2018) found significant improvements in dyspareunia and dysmenorrhea after six and twelve months of LNG-IUD use following abortion, with no significant changes in women using SARC methods. Research has also demonstrated that LNG-IUDs improve dysmenorrhea in women with endometriosis (Lockhat et al., 2004; Vercellini et al., 2003). Lockhat et al. (2004) found that among women with endometriosis, the LNG-IUD was effective in treating symptoms including irregular menstrual bleeding and abdominal pain. Taken together, it appears as though hormonal IUDs may reduce pain associated with menstruation and intercourse.

To a similar effect, LNG-IUDs may also improve symptoms of menorrhagia. Among 60 women treated for menorrhagia with an LNG-IUD, Gorgen et al. (2009) reported a significant decrease in pelvic pain over the course of six months of treatment. Gorgen et al. (2009) suggested that this decrease in pain could be explained by the cessation of heavy bleeding related to uterine cramps often reported by LNG-IUD users. Research has also shown that among women with heavy menstrual bleeding, LNG-IUDs may be helpful in reducing bleeding and enhancing quality of life (Hubacher et al., 2009). In a systematic review and meta-analysis of RCTs comparing endometrial ablation and LNG-IUD insertion for the treatment of heavy menstrual bleeding, Kaunitz et al. (2009) found that, of the six studies that assessed quality of life, five found both treatments to be associated with improvements in quality of life. Therefore, hormonal IUDs may reduce sexual pain by improving symptoms of gynecological conditions, such as endometriosis or menorrhagia. These positive findings are especially relevant to women with existing gynecologic complaints, as LNG-IUDs may offer therapeutic benefits. Although, this effect may be unique to LNG-IUDs. Skrzypulec and Drosdzol (2008) found that LNG-IUD users reported less pain than other IUD users and women using no contraceptives. Research has also shown that Cu-IUD use is associated with increases in menstrual bleeding and cramps (Bilian, 2002; Li et al., 2016), and does not present the same therapeutic effects of LNG-IUDs on gynecologic conditions. It is therefore unsurprising that Cu-IUD use does not present the same improvement in sexual pain.

Results from this review also indicate that there may be positive or neutral effects on sexual desire among IUD users. These results were indicated by a majority of moderate or high quality studies. Four longitudinal studies reported no changes in desire over three to four (Li et al., 2004), six (Sharma, 1972; Suhonen et al., 2004), and twelve (Martin-Loeches et al., 2003; Suhonen et al., 2004) months. Four longitudinal studies reported significant improvements in desire over six (Caruso et al., 2018; Gorgen et al., 2009), eleven (Herzberg et al., 1971), and twelve (Bastianelli et al., 2011) months. As such, there does not appear to be a uniform effect of IUDs on sexual desire, and more research is therefore needed in this area. Regarding studies that found improvements in sexual desire among IUD users, there are a number of possible explanations. For example, an increase in desire could be due in part to reduced fears of pregnancy through the use of contraceptives, as Graham et al. (2004) found fears of unwanted pregnancy to have a detrimental effect on sexual arousal. Another potential explanation offered by Gorgen et al. (2009) is that an increase in sexual desire may be a result of an improvement in general well-being, as the authors also found significant increases in quality of life measures among LNG-IUD users. Other studies reported IUD use may increase sexual frequency (Chen & Ho, 1999; Oddens, 1999; Sharma, 1972) and spontaneity (Oddens, 1999), as well as decrease sexual distress (Caruso et al., 2018). These may represent other manifestations of increased desire or related phenomena. These findings are especially useful for women who have concerns about contraceptive methods impacting their sexual desire.

Results from this review suggest that there may not be any notable impact of IUDs on the domains of arousal, lubrication, orgasm, and satisfaction. These results were synthesized from only moderate and high quality studies. Rather, recent research suggests that factors related to sociocultural influences and personal health may be more influential on these domains than are IUDs. For example, Toorzani et al. (2010) found no significant differences in sexual satisfaction across multiple contraceptive methods, including IUDs and OCPs. In conceptualizing these findings, Toorzani et al. (2010) suggested that cultural differences and a lack of sexual health awareness in reaching orgasm and satisfaction led to any low levels of sexual satisfaction in their sample.

Similarly, studies that examined the effects of IUDs on overall sexual function largely found no notable effects (Ertekin Pinar et al., 2019; Ferreira et al., 2019; Higgins et al., 2016; Koseoglu et al., 2016; Neri et al., 2018; Panchalee et al., 2014; Umran & Melike, 2016). These studies were all assessed as moderate or high quality. One of these studies (Panchalee et al., 2014) found that, whereas there were no significant differences in rates of sexual dysfunction among three variants of the Cu-IUD users, individuals with lower body mass index (BMI) reported higher rates of sexual dysfunction, suggesting that BMI may have a greater impact on sexual function than IUDs. Similarly, Umran and Melike (2016) found no significant differences in overall function across multiple contraceptive methods, including IUDs, though total FSFI score decreased with age. From these findings, they proposed that other psychological, social, and biological factors, such as age, may have a stronger influence on overall function than contraceptive method choice. Taken together, it appears as though IUDs are minimally impactful on many aspects of women’s sexual function. These results are especially meaningful to women currently using contraception, women considering contraception, and healthcare professionals (i.e., OBGYNs, family medicine physicians) who practice contraceptive counseling.

A strength of this review is the large number of studies from multiple countries, including Turkey, Italy, Sweden, China, Germany, and the United States. This diversity increases the generalizability of these findings. This review also has a number of limitations. First, the scarce amount of randomized controlled trials limits the external validity of these findings. Though there is one RCT included in this review (Hurskainen et al., 2004), there is a great need for more. Due to this lack of random assignment, the women who choose one method may differ from the women who choose another method, resulting in effects that may confound the findings. Another limitation of this review is that the included papers used multiple assessment devices, including the FSFI, McCoy Female Sexuality Questionnaire (MSFQ), and the National Survey of Sexual Attitudes and Lifestyles Sexual Function Scale (Natsal-SF), as well as author constructed scales that are not validated. Inconsistent assessment methods make it difficult to standardize effects across studies. Additionally, only English-language papers were included in this systematic review. With papers not available in English being excluded, our results are biased toward papers that were already in English or could easily be translated. This could have confounded the results of the review as research has found that authors are more likely to publish in an English-language journal if the results are significant (Egger et al., 1997). Finally, a few papers did not specify which types of IUD (Cu- or LNG-IUD) were used by the participants, which made it impossible to discriminate the effects of hormonal or non-hormonal IUDs in these studies.

As results from this review indicate there are positive effects of LNG-IUDs on sexual pain, future research should explore this connection further by examining possible interactions from sociocultural, physiological, and psychological influences. Additional research exploring the effects of contraceptives on sexual desire is also warranted to confirm the true impact of IUDs. Finally, as only one of the included studies was a randomized controlled trial (Hurskainen et al., 2004), additional RCTs should be conducted to measure effects on sexual function with limited bias.

In conclusion, it appears as though LNG-IUDs reduce sexual pain in women. IUDs may also increase sexual desire, although more research is needed to support this finding. There does not appear to be a marked impact of IUDs on arousal, lubrication, orgasm, satisfaction, or overall sexual function in women. This systematic review highlights the potentially beneficial impact of LNG-IUDs on sexual pain and the need for more research to expand upon the existing knowledge of sexual acceptability in contraceptive method users.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

IRB statement

This systematic review was exempt from IRB approval.