Can an intrauterine device cause dyspareunia (pain during intercourse)?

Can Pain During Intercourse Occur with an IUD?

Yes, an IUD can cause dyspareunia (pain during intercourse), though this is not a commonly emphasized side effect in major guidelines and typically indicates a problem requiring evaluation.

Understanding IUD-Related Dyspareunia

While major contraceptive guidelines 1, 2 do not list dyspareunia as a typical expected side effect of properly positioned IUDs, research evidence demonstrates that sexual pain can occur with IUD use and warrants clinical attention 3.

Evidence for IUD-Associated Sexual Pain

A 2016 comparative study found that copper IUD users experienced:

• Significantly lower pain domain scores on validated sexual function assessments compared to women without contraception
• Decreased arousal, lubrication, and orgasm scores, likely secondary to the pain
• The copper IUD status was the strongest predictor of sexual pain in multivariate analysis 3

When to Suspect a Problem

Dyspareunia in an IUD user should raise immediate suspicion for device malposition or complications, not simply be dismissed as a normal side effect. Key scenarios include:

Device Malposition or Migration

• IUD perforation into the myometrium can present with pelvic pain and dyspareunia, even when strings remain visible at the cervix 4
• Intravesical migration (bladder penetration) causes dyspareunia, urinary symptoms, and recurrent infections 5, 6
• These complications require imaging (ultrasound) and often surgical removal

Pelvic Inflammatory Disease

• IUDs increase PID risk primarily in the first 21 days after insertion 1
• Beyond this period, IUDs do not increase baseline PID rates
• PID can present with dyspareunia and requires treatment, though the IUD can often remain in place during antibiotic therapy 2

Clinical Approach

When an IUD user reports dyspareunia:

1. Verify device position - Visible strings do NOT exclude malposition 4
2. Perform pelvic ultrasound to confirm intrauterine location
3. Screen for STIs if risk factors present
4. Evaluate for other causes of deep dyspareunia (endometriosis, pelvic floor dysfunction, adhesions)

Important Distinction

The levonorgestrel IUD actually reduces dyspareunia in women with endometriosis by decreasing pelvic pain 7, 8. If a patient with a hormonal IUD develops new dyspareunia, this strongly suggests a mechanical problem rather than a hormonal effect.

Key Clinical Pitfalls

• Do not assume visible strings mean proper positioning - perforation can occur with strings still visible 4
• Do not dismiss dyspareunia as "normal" with IUDs - it warrants investigation
• Consider imaging even with visible strings if pain symptoms are present
• The copper IUD appears more associated with sexual pain than hormonal IUDs 3

Bottom line: While properly positioned IUDs should not cause dyspareunia, any patient reporting this symptom requires evaluation for malposition, infection, or other pelvic pathology rather than simple reassurance.