---
title: "Oral contraceptive formulation and everyday attentional engagement: no association found"
id: "plos-one-19-revisiting-the-relation-between-oral-contraceptive-use-and-attentional"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-19-revisiting-the-relation-between-oral-contraceptive-use-and-attentional"
content_type: "clinical_feed_article"
specialty: "Neurology"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0359652"
published_at: "2026-10-06T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Oral contraceptive formulation and everyday attentional engagement: no association found
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-19-revisiting-the-relation-between-oral-contraceptive-use-and-attentional
- **Specialty:** [Neurology](https://medichelpline.com/clinical-feed/neurology.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0359652)
- **Published At:** 2026-10-06T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- Oral contraceptives (**OCs**) contain synthetic estrogens (ethinyl-estradiol) and/or progestins that can bind brain receptors and potentially influence cognition, including attention-related processes. - Early small-sample work suggested OC use increased **mind wandering**, but two larger replications found little evidence linking OC use to increased inattentiveness when collapsing across formulations. - This study tested whether OC **formulation** (brand-derived dose, dosing schedule, hormonal activity, and progestin generation) moderates relations between OC use and trait-level attention measures. - Data were secondary from University of Waterloo Pre-screen and Mass Testing surveys collected across five semesters (Fall 2023–Winter 2025), yielding 2,578 participants after exclusions: 355 OC users and 2,223 non-users. - Exclusions removed participants using non-OC hormonal methods, those pregnant/breastfeeding, currently treated for depression/anxiety, duplicate entries, poor-quality responses, and incomplete reporting on contraceptive status. - Trait measures included spontaneous and deliberate **mind wandering** scales, attention lapses, attention-related errors, **boredom proneness**, and flow; self-report measures validated in prior research were used. - OC brand names reported by participants were used to derive formulation variables: ethinyl-estradiol dose, progestin dose, dosing schedule (monophasic/triphasic/progestin-only), and estrogenic/progestational/androgenic activity. - Length of current OC use was rarely reported (only 35 participants), so analyses involving duration were underpowered; exploratory analyses found no significant correlations between length of use and attention measures (ps > .062). - The study found no evidence that different **OC formulations** related to differences in trait-level attention measures; collapsing across formulations, OC users did not differ significantly from non-users on these attention traits. - The authors conclude that OC users can be treated as a homogeneous group for trait-level attentional engagement in this dataset, but note limitations including reliance on self-report measures and limited duration-of-use data. - Anonymized data and analysis scripts are available on the Open Science Framework at the URL reported in the source article.
## Clinical Analysis & Structured Key Points
Revisiting the relation between oral contraceptive use and attentional engagement in everyday life: The role of formulation | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Oral contraceptives (OCs) are composed of artificial estrogen (ethinyl-estradiol) and/or progesterone (progestin), which can attach to receptors in the brain and potentially influence cognition. One prior study suggested that OC use was associated with increased mind-wandering – implying that OC use was associated with detriments to attention. In contrast, two subsequent well-powered conceptual replications of this initial finding revealed little evidence that OC use was related to increases in inattentiveness (including mind-wandering). However, these later studies collapsed across different OC formulations, which may obscure effects specific to particular formulations. In the present study, we investigated the possibility that OC formulation might differentially relate to attention-related traits. To do this, we collected trait-level reports of the tendency to experience attention related errors, attention lapses, spontaneous and deliberate mind-wandering, boredom, and flow in undergraduate females using OCs, and we collected the brand of OC used from which it was possible to derive the formulation. OC formulations differed in ethinyl-estradiol dose, progestin dose, dosing schedule, hormonal activity (or potency), and the type (or ‘generation’) of progestin used. We found no evidence that different OC formulations were related to differences in attention-related traits, which suggests that OC users can be treated as a homogenous group when examining trait-level attention. Comparisons of OC users (collapsing across formulation) to non-users again revealed no significant differences in trait-level attention. Citation: Smith AC, Smilek D (2026) Revisiting the relation between oral contraceptive use and attentional engagement in everyday life: The role of formulation. PLoS One 21(10): e0359652. https://doi.org/10.1371/journal.pone.0359652 Editor: Quazi Maksudur Rahman, East West University, BANGLADESH Received: February 25, 2026; Accepted: September 16, 2026; Published: October 6, 2026 Copyright: © 2026 Smith, Smilek. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: Anonymized data and analysis scripts are available on the Open Science Framework: https://osf.io/myad4/overview . Funding: This research was supported by a Natural Sciences and Engineering Research Council of Canada (NSERC) Discovery Grant awarded to Daniel Smilek, an NSERC Alexander Graham Bell Canada Graduate Scholarship – Doctoral awarded to Alyssa Smith, and an NSERC Postdoctoral Fellowship awarded to Alyssa Smith. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. https://nserc-crsng.canada.ca/en . Competing interests: The authors have declared that no competing interests exist. Introduction More than 150 million women around the world use oral contraceptives [ 1 ]. Oral contraceptives are a type of hormonal contraceptive composed of ethinyl-estradiol and/or a synthetic form of progesterone known as progestin [ 2 ]. In naturally cycling individuals, estradiol and progesterone typically fluctuate over the course of the menstrual cycle. In contrast, OCs deliver a low consistent dose of synthetic versions of these hormones, suppressing the endogenous (or naturally occurring) estradiol and/or progesterone and replacing them with artificial surrogates [ 2 ]. This suppression of estradiol and/or progesterone (and replacement with artificial surrogates) is important because this process not only occurs in the reproductive system, but also systemically throughout the body. That is, estradiol and progesterone are also synthesized in areas of the brain responsible for higher order cognition (e.g., in the prefrontal cortex), which contain receptors for these hormones [ 3 , 4 ]. Since these molecules can function as neurosteroid hormones, they have the potential to modulate the neural excitability and neural circuits underlying many cognitive functions [ 5 , 6 ]. Accordingly, there has been a growing interest in gaining a better understanding of if and how the artificial hormones in OCs may be related to cognitive performance [ 7 – 9 ]. Reviews of the relations between OC use and cognition (see Warren et al [ 7 ]; Gurvich et al [ 8 ]; Beltz [ 9 ] typically categorize cognitive performance into several cognitive domains (e.g., memory, spatial perception, attention). One domain that had not been well examined is ‘attention’, and particularly processes related to sustained attention, such as mind wandering (i.e., engagement in task-unrelated thoughts). As of this writing, just two studies examined the relation between OC use and mind wandering [ 10 , 11 ]. In the first study addressing this issue, Raymond et al [ 10 ] examined self-reports of mind wandering among small samples of OC users (N = 28), OC non-users (N = 14), and men (N = 29). They claimed that OC users had an increased frequency of mind wandering compared to non-users. These results were in the expected direction given the increased risk of depression among OC users, and they were concerning, suggesting that OC use might be detrimental to attention. If this was in fact the case, women ought to know this risk when making the decision to begin using an OC. In the second study, we [ 11 ] aimed to replicate and extend the work of Raymond et al [ 10 ] with (1) a larger sample of participants, (2) validated measures of attentional engagement in everyday life (including a measure of mind wandering), and (3) a verification of our results across two large independent samples (OC users Sample 1: N = 471; Sample 2: N = 246; those not using any form of hormonal contraceptives including OCs, Sample 1: N = 1330; Sample 2: N = 929). Participants completed self-report measures of their trait-level tendency to experience spontaneous and deliberate mind wandering, attention lapses, and attention-related errors. In Sample 1, we found that compared to non-users, those using OCs reported a significantly lower propensity to experience spontaneous and deliberate mind wandering; there were also no differences between groups with regard to the tendency to experience attention lapses and attention-related errors. However, the effect sizes of the differences in mind wandering between groups were small in size ( d s = 0.17, 0.20). In our second independent sample (Sample 2), we found no significant differences on any of our attention measures between groups. As such, given that the effect sizes in Sample 1 were small, and there were no significant effects observed in Sample 2, we concluded that OC use was not reliably associated with variations in trait-level attention [ 11 ]. While our results showed that the tendency to experience mind wandering, attention lapses, and attention-related errors was not reliably related to OC use, other attention-related traits could be. In a follow-up study we explored whether OC use was related to the tendency to experience boredom and flow [ 12 ]. Boredom is defined as an aversive state that arises when an individual is unable to successfully engage their attention with an internal (e.g., thoughts) or external activity, even though they may want to 24 . On the flip side, flow has been described as a state where individuals report being completely absorbed in a task where the full extent of their skills is used, while still being able to successfully complete that task. Most importantly, a side effect of this flow state is the lack of boredom or worry to the point where individuals can become oblivious to their surroundings [ 13 ]. While boredom and flow are often discussed as momentary states, there are also stable trait-level differences in how frequently individuals experience these states [ 13 – 16 ]. To examine the linke between OC use and these traits, we utilized a similar method to prior work examining attention-related traits. We found OC use was associated with decreased boredom proneness but no significant differences between groups in terms of internal or external flow. In hierarchical regressions predicting boredom, we entered depression, anxiety, and stress symptoms and the semester of data collection in the first step before adding OC use in the second step. This allowed us to examine the unique contribution of OC use by controlling for depression, anxiety, and stress symptoms and the semester of data collection. We found OC use was a unique and significant predictor of boredom proneness. This suggests that OC users and non-users differ in terms of boredom proneness, but that this difference is independent of mental health symptoms and the semester of data collection. Taken together, our prior studies examining attentional engagement in everyday life and boredom and flow [ 11 , 12 ] revealed that OC use does not reliably relate to a variety of attention-related factors (i.e., attention-related errors, attention lapses, spontaneous and deliberate mind wandering, and internal and external flow), with the exception of the trait propensity to experience boredom [ 12 ]. One potentially important limitation of both studies was a lack of information about the formulations of the OCs being used by those in the OC group. OC brands are known to vary in the doses of the synthetic hormones they include, dosing schedule, and estrogenic, progestational, and androgenic activity. It is possible that different OC formulations may act differently on the brain and produce different behaviours as evidenced by different OC formulations being associated with varying risks of developing depression [ 17 ]. By not considering the various formulations of the OCs used, we may have obscured effects that are specific to particular formulations [ 18 – 20 ]. As an example of the possible moderating role of formulation is a study by Beltz et al [ 19 ]. They examined performance on a mental rotation task among women using OCs (with monophasic and triphasic dosing schedules), naturally cycling women, and men. When they collapsed across OC formulation, they found that women using OCs did not significantly differ from naturally cycling women, but when OC formulation was considered, women using monophasic OCs significantly differed from naturally cycling women such that monophasic OC users outperformed naturally women. In a separate study examining mental rotation, researchers again found that mental rotation performance did not significantly differ between OC users and non-users. However, they did find that the relation between self-perceived masculinity and performance on a mental rotation task among naturally cycling women and OC users was moderated by the estrogenic and progestational activity of OCs. This made us wonder if OC users and non-users may similarly differ in terms of attention-related traits once we accounted for the dosing schedule and/or the estrogenic, progestational, and androgenic activity of the OC used. To address this limitation, in the present study we aimed to examine whether collapsing across OC formulation obscured differences in everyday attentional engagement. To do this, we collected data regarding OC brand as well as duration of OC use in order to determine whether there were effects of specific formulations on attentional engagement. Like our prior work, we focused on OC use (opposed to hormonal contraceptives more broadly) as prior work has suggested that the oral delivery of exogenous hormones could be associated with different metabolic and by extension, cognitive effects than other delivery methods [ 21 ]. As in our previous studies, we collected self-report trait-level measures of attention related errors, spontaneous and deliberate mind wandering, attention lapses, boredom proneness, and flow using reliable and validated questionnaires. While self-report measures do have limitations, there is also evidence that self-reports are better predictors of everyday behaviours than some task-based behavioural measures [ 22 ]. We aggregate data across five semesters (Fall 2023, Winter 2024, Spring 2024, Fall 2024, and Winter 2025) to achieve a larger sample. Our main objectives were as follows: 1) replicate the overall null relations between OC use and everyday attentional engagement we reported previously [ 11 , 12 ]; and 2) then examine the role of OC formulation to determine whether collapsing across OC formulations obscured effects of specific formulations. Method Participants This study utilized secondary data. All participants provided informed consent online (indicating their consent via the use of ratio buttons). Participants were recruited between September 5 2023 and April 1 2025. Participants in the secondary dataset were undergraduate students enrolled in at least one psychology course at the University of Waterloo who indicated their sex as female. In exchange for completing the Pre-screen and Mass Testing surveys (see below), participants received partial course credit. Since our goal was to determine whether our prior work [ 11 ] collapsing across OC formulation obscured differences in everyday attentional engagement, we aimed to collect data using the same recruitment techniques. Participants were then screened for the a priori determined exclusion criteria by semester based on the criteria outlined in the Data Cleaning section below. (We note that while a large proportion of participants were excluded, data was not collected for the sole purpose of the present study. Rather, the Prescreen and Mass Testing surveys are constructed for all researchers in the Psychology Department. As such, for the data to be utilized for the present study, inclusion criteria was applied following data collection.) Data were collected across 6 semesters: Fall 2023 sample (accessed November 15, 2023; N = 1546), Winter 2024 (accessed March 20, 2024; N = 1371), Spring 2024 (accessed July 26, 2024; N = 428), Fall 2024 (accessed November 27, 2024; N = 1554), and Winter 2025 sample (accessed April 2, 2025; N = 1459). Exclusion criteria and exclusion Ns are listed in Table 1 . The total sample included in the data analysis collapsed across all semesters included a total of 2578 participants, with 355 OC users and 2223 were non-users. The total sample split by semester and OC status are included in the bottom of Table 1 . Download: PNG larger image TIFF original image Table 1. Exclusion criteria and Ns of excluded participants by semester. https://doi.org/10.1371/journal.pone.0359652.t001 Pre-screen and Mass Testing Surveys Data was collected at the University of Waterloo as a part of the Pre-screen and Mass Testing surveys, which are questionnaires completed the beginning of each semester by undergraduates enrolled in psychology courses. The Pre-screen survey included items asking about sex, gender, age, current hormonal birth control use, length of current birth control use (only 35 participants provided a clear response in terms of the length of time they had used OCs. As such, we were underpowered to length of use as a mediator or moderator in the subsequent analyses. Exploratory analyses revealed no significant correlations between length of use and our attention measures: all ps > .062), current hormonal birth control brand name, past hormonal birth control use, length of past hormonal birth control use, time since past hormonal birth control use, and current pregnancy/breastfeeding. The hormonal birth control item was, “Are you currently using one of the following methods of birth control?” Participants responded by selecting from a list that included: oral contraception (i.e., birth control or “the pill”), birth control patch, vaginal ring, birth control injection, copper IUD, hormonal IUD, hormonal implant, none of the above, and prefer not to answer. We used the OC brand provided by participants to derive the composition (the type and dose of ethinyl estradiol and/or progestin), the dosing schedule (monophasic, triphasic, or progestin only), as well as the estrogenic, progestational, and androgenic activity of each OC [ 23 ]. Importantly, since data were collected as part of a larger test battery, all participants were blind as to the research question. Data Cleaning We utilized a similar data cleaning procedure as in our prior work [ 11 , 12 , 24 ]. Exclusion criteria were determined a priori unless otherwise stated. For all semesters, participants were excluded based on the following criteria: 1) inclusion in a previous semester of data (to ensure no participants were double counted; not applicable for Fall 2023 as the first semester of data collection), 2) use of a hormonal contraceptive other than OC, 3) use of an IUD, 4) failing to disclose whether or not they used a hormonal contraceptive, 5) current pregnancy or breastfeeding (due to a coding error in Winter 2025, the response options for the item asking participants whether they were pregnant or breastfeeding only included “no”. However, participants were not required to respond to all items. Since the inclusion criteria for this item is “no”, we reasoned that those who indicated no were indicating they were not pregnant or breastfeeding, while those who did not respond may have been pregnant or breastfeeding. As such, like the previous samples we only included those who responded “no”.), and 6) failing to disclose whether or not they were pregnant or breastfeeding. To avoid the possible confound of mental health, participants who reported that they were currently receiving treatment for depression or anxiety were excluded (the exogenous hormones in OCs could also interact with psychotropic medications; see Damoiseaux et al [ 25 ]). Participants who did not respond to the items related to the reception of treatment for depression and anxiety were also excluded. Data quality checks were conducted to eliminate poor quality data based on participants’ patterns of responses. Participants were removed prior to analyses if a) the number of clicks they made was fewer than the number of responses per page of a survey, b) their responses were faster than 1-second per scale item on more than 50% of the scales of interest (to respond in good faith, we reasoned participants needed at least 1-second per item to read and respond. If they were faster than this on >50% of the scales we removed them because this may indicate they were responding randomly), and c) participants responded to fewer than half of the items on a scale of interest (as responses on items for a given scale were averaged to calculate scale scores). We analyzed the data with and without exclusions based on age (to target participants of reproductive age; 18–45 years old). This did not change the results in a meaningful way. The below analyses exclude participants who were older than 45 or did not report their year of birth. Materials Spontaneous (MWS) and deliberate (MWD) mind wandering scales The MWS is a self-report measure of spontaneous (or unintentional) mind wandering, while the MWD measures deliberate (or intentional) mind wandering [ 26 ]. These questionnaires are composed of 4 statements each. Example items include: “I allow my thoughts to wander on purpose” (MWD), and “I find my thoughts wandering spontaneously” (MWS). Participants are asked to rate each item on a seven-point scale that ranges from 1 (rarely) to 7 (a lot). Higher scores indicate a greater tendency to engage in mind wandering (deliberat
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