Hormones and Behavior 119 (2020) 104652

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Hormones and Behavior

journal homepage: www.elsevier.com/locate/yhbeh

Hormonal contraceptive use predicts decreased perseverance and therefore T

performance on some simple and challenging cognitive tasks
⁎
Hannah K. Bradshaw , Summer Mengelkoch, Sarah E. Hill
Department of Psychology, Texas Christian University, United States of America

A R T I C LE I N FO A B S T R A C T

Keywords: A growing body of research suggests that hormonal contraceptive (HC) use may be associated with lower self-
Hormonal contraceptives control, as well as structural and functional differences in women's brains that could contribute to differences in
Perseverance perseverance on tasks requiring cognitive control. Here, we sought to extend this research by examining the
Performance relationship between HC use and college-aged women's perseverance (i.e., time spent) and performance on tasks
Cognitive control
requiring cognitive control. Across two studies, we find that, compared to naturally-cycling women, women
Executive function
Self-regulation
using HCs display less perseverance on both simple (i.e., a spot-the-difference game) and challenging (i.e.,
Graduate Record Examination quantitative problems) tasks. Moreover, these differences in perseverance were
found to predict performance decrements across tasks, with women taking HCs performing worse because they
spent less time on the tasks. By demonstrating how HC use may influence perseverance and thereby perfor-
mance, these results contribute to a growing body of research examining the unintended implications of HC use
on cognition, learning, and memory.

If at first you don't succeed, try, try again. The familiar adage may variability in perseverance (Warren et al., 2014). However, a growing
be based on folk wisdom, but it appropriately highlights the incredible body of research suggests that HC use may be associated with important
power of perseverance in achieving success. For example, research structural and functional differences in brains areas important for ex-
suggests that the ability to persist on difficult tasks is highly predictive ecutive function and the cognitive control of behavior (Hertel et al.,
of success in several domains of life, including learning and educational 2017; Kirschbaum et al., 1999; Petersen et al., 2014; Petersen et al.,
attainment (Pintrich et al., 1993; Zimmerman and Pons, 1986), job 2015; Pletzer et al., 2016). As such, HC use could contribute to ob-
performance (Littman-Ovadia and Lavy, 2016; Robertson-Kraft and served differences in perseverance and task performance in women.
Duckworth, 2014), well-being (Salles et al., 2014), and academic Here, we test this possibility by examining whether HC use in college-
achievement (Muenks et al., 2017). For example, in one study of more aged women is associated with perseverance and performance decre-
than 600 full-time employees, researchers found that perseverance was ments on tasks requiring the ability to exercise cognitive control of
the trait that was most positively related to effective work performance behavior. We hypothesized that women taking HCs (when compared to
and most negatively related to counterproductive work behaviors, such naturally-cycling women) would exhibit diminished perseverance on
as calling in sick for reasons other than illness (Littman-Ovadia and both simple and challenging cognitive tasks. We further hypothesized
Lavy, 2016). Others have found perseverance to be predictive of success that the predicted differences in perseverance would predict diminished
benchmarks as diverse as retention in the United States Military task performance by HC using women. This research will help inform
Academy and ranking in the National Spelling Bee (Duckworth et al., the continued discussion about the potentially far-reaching effects of
2007). Together, such research suggests that the ability to persevere HCs on women's psychology and behavior.
and work diligently toward goals plays an important role in achieving HCs were first approved for use in pregnancy prevention by the
success in a variety of important life domains. United States Food and Drug Administration in 1960 (Engelman, 2001).
While much research has investigated the importance of persever- Today, nearly 60 years later, approximately 11.2 million women in the
ance in success across life domains (Credé et al., 2017), less attention United States take HCs, making them the most commonly used method
has been given to the role that hormones, generally, or hormonal of contraception (Jones, 2011; Kavanaugh and Jerman, 2018). The
contraceptives (HC), specifically, play in contributing to observed majority of women taking HCs do so for contraceptive purposes (i.e.,

⁎
Corresponding author at: Department of Psychology, Texas Christian University, 2955 S. University Drive, Fort Worth, TX 76129, United States of America.
E-mail address: [email protected] (H.K. Bradshaw).

https://doi.org/10.1016/j.yhbeh.2019.104652
Received 17 April 2019; Received in revised form 29 October 2019; Accepted 28 November 2019
Available online 12 December 2019
0018-506X/ © 2019 Elsevier Inc. All rights reserved.
H.K. Bradshaw, et al. Hormones and Behavior 119 (2020) 104652

avoiding unwanted pregnancy). However, many women use HCs for memory, recognition memory, mental rotation, verbal fluency, visuos-
non-contraceptive benefits, such as reducing pain associated with patial abilities, and attention (Islam, Sparkes, Roodenrys, & Astheimer,
menstruation, menstrual cycle regulation, and acne reduction 2008; Mordecai et al., 2008; Wharton, Hirshman, Merrit, Doyle, Paris,
(Burkman et al., 2004). & Gleason, 2008; Wright Jr and Badia, 1999).
In addition to inhibiting ovulation (the primary mechanism through Importantly, much of the research examining the links between HC
which HCs prevent pregnancy), HC use is also associated with several use and performance on tasks requiring cognitive control has been
additional physiological and psychological effects (see Montoya and conducted using small sample sizes and without examining the re-
Bos, 2017; Pletzer and Kerschbaum, 2014; Welling, 2013 for review). lationship between HC use, perseverance, and performance on tasks
For example, HC use is associated with decreased risk of ovarian cancer requiring cognitive control (with exceptions; see e.g., Griksiene et al.,
(Beral et al., 2008), but increased risk for thrombotic stroke, myocardial 2018). The literature is currently lacking research conducted on large
infarction (Lidegaard et al., 2012), and breast cancer (Kahlenborn et al., samples that examines the relationship between HC use, perseverance,
2006). and performance on tasks requiring cognitive control.
Although less frequently discussed, research suggests that HC use Given this current empirical gap, we designed two studies to ex-
may also have effects on women's brain structure and function. Many of amine the relationship between HC use and women's perseverance and
these differences are in areas that play an important role in executive performance on simple and challenging cognitive tasks. Others have
function and the cognitive control of behavior. For example, compared found that, compared to naturally-cycling women, women taking HCs
to naturally-cycling women, women using HCs exhibit decreased exhibit diminished performance on a relatively complex mental rota-
resting state functional connectivity in the brain's executive control tion task (Griksiene et al., 2018; Griksiene and Ruksenas, 2011). In
network (Petersen et al., 2014; Pletzer et al., 2016), which plays an Study 1, we sought to examine whether such differences are also ob-
important role in self-regulatory behaviors such as attention, learning, served using a simple visuospatial task, and whether the predicted
and memory (Rueda et al., 2004). Others find that HC users have de- decrements in performance are mediated by decreased perseverance.
creased cortical thickness in the lateral orbitofrontal cortex and the Specifically, we used a timed spot-the-difference task to assess differ-
posterior cingulate cortex (Petersen et al., 2015), areas which are ences in perseverance and performance between naturally-cycling
known to play an important role in self-regulation and executive women and those using HCs. This task was chosen because it has been
function (Wagner et al., 2001). used successfully in past research aimed at assessing attention (Fukuba
HC users and non-users also exhibit differences in the hippocampus, et al., 2009; Kreplin and Fairclough, 2013) and differences in cognition
with HC users having less hippocampal volume than non-users (Hertel stemming from structural and functional changes in the brain
et al., 2017). This difference is reasoned to emerge in response to HC (Nishiguchi et al., 2015).
users experiencing hypercortisolism. That is, women taking HCs have In Study 2, we sought to conceptually replicate and extend Study 1,
higher total cortisol levels than do naturally-cycling women (Hertel examining whether HC use is also associated with decreased persever-
et al., 2017; Kirschbaum et al., 1999), which can suppress cell pro- ance and performance on more challenging and meaningful tasks. In
liferation (and may contribute to cell death) in the hippocampus (Gould particular, we examined the relationship between HC use and women's
and Tanapat, 1999; Sapolsky et al., 1985; Woolley et al., 1990). Al- perseverance and performance on complex arithmetic problems (taken
though this area of the brain is most frequently studied in terms of its from a Graduate Record Examination [GRE] practice book) and both
direct impact on learning and memory (Axmacher et al., 2007; Meck solvable and unsolvable anagrams. The GRE and solvable anagram
et al., 1984; Rawlins and Tsaltas, 1983), the hippocampus also plays a tasks were chosen because performance on math and language tasks are
role in perception (Lee et al., 2005), as well as motivation and emotion each associated with the ability to exercise cognitive control of beha-
(Frodl et al., 2006; Gray and McNaughton, 1983). vior (Cragg and Gilmore, 2014; Cragg et al., 2017; Finn et al., 2014;
In addition to being associated with changes in brain structure and Gilhooly and Fioratou, 2009; Mendelsohn et al., 1966; Novick and
function, research finds that HC use may also have an important impact Sherman, 2003). The unsolvable anagram task was chosen based on
on women's psychology and behavior, particularly in domains related past research which has demonstrated its utility as a measure of per-
to cognitive control of behavior. For example, in one recent highly- sistence in the face of perceived failure (Eisenberger and Leonard, 1980;
powered, randomized, placebo-controlled study, researchers found Kroll, 1991; Ventura et al., 2013). Given the demonstrated impact of HC
evidence of a causal association between HC use and self-control, with use on brain structures related to cognitive control and working
women using HCs reporting lower self-control relative to the placebo memory, we predicted that women using HCs would exhibit decrements
group (Zethraeus et al., 2017). Others have found that HC use is asso- in perseverance and performance across both simple and challenging
ciated with higher likelihood of academic performance problems in a tasks. Further, we predicted that the relationship between HC use and
sample of young female college students (Gregory et al., 2018), sug- performance would be mediated by changes in perseverance, where
gesting that cognitive control of behavior may be diminished in HC- women taking HCS perform worse than naturally-cycling women be-
using women. cause they spend less time on the tasks.
Despite these empirical linkages, research examining the relation-
ship between HC use and performance on tasks requiring cognitive 1. Materials and methods
control has been largely inconclusive (for review see Warren et al.,
2014). Some research finds, for example, that compared to non-users, 1.1. Participants
HC use is associated with impaired performance on mental rotation and
verbal fluency tasks, as well as mental math (Griksiene et al., 2018; Participants for both studies were recruited from a private uni-
Griksiene and Ruksenas, 2011; Wuttke et al., 1975). For instance, versity in the southern U.S. The inclusion criterion for duration of HC
Griksiene et al. (2018) found that HC users responded more quickly and use was at least two months. Women who were naturally-cycling were
less accurately than naturally-cycling women on mental rotation tasks, required to have not used HCs for at least three months. All participants
which is consistent with the idea of reduced cognitive control in the received nominal course credit for participation.
context of HC use. However, others find that HC use is associated with The final sample of participants for Study 1 consisted of 149 female
better spatial ability (specifically monophasic oral contraceptives; undergraduates (73 on hormonal birth control; Mage = 20.24,
Beltz, Hampson, & Berenbaum, 2015), quicker reaction times, and SDage = 2.86). Prior to data analysis, participants were excluded if
improvements in working memory (Griksiene and Ruksenas, 2011). they: were pregnant or breast feeding (n = 1), self-reported having a
Others find no relationship between HC use and performance on tasks hormonal disorder (n = 14), failed attention filters (n = 8), or did not
requiring cognitive control, including working memory, visuospatial meet recruitment criteria for age or HC duration (n = 5).

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H.K. Bradshaw, et al. Hormones and Behavior 119 (2020) 104652

The final sample of participants for Study 2 consisted of 175 female eight math problems one at a time. An example problem is, “If an in-
undergraduates (89 on hormonal birth control; Mage = 19.28, teger is divisible by both 8 and 15, then the integer also must be di-
SDage = 1.58). Prior to data analysis, participants were excluded if visible by which of the following?” Each math problem was accom-
they: indicated they had a hormonal disorder (n = 13); failed attention panied by five potential answer options. A total performance score was
filters (n = 19); or did not meeting the recruitment criteria for age or computed by summing the number of correct responses for each par-
birth control duration (n = 3). ticipant. Time spent on each problem was measured via the timing
feature in Qualtrics. As a measure of perseverance on the GRE task, a
1.2. Procedure mean composite of time spent was computed by averaging the time
spent across each problem.
All sessions were conducted between 8 and 10:30 A.M. Participants
arrived at a research laboratory in small groups of 5–12 to participate in 1.3.3. Anagram tasks
a study allegedly examining the relationship between personality and Participants were told that the purpose of the task was to examine
problem solving. All participants were seated at individual computer how they interpret ambiguous word stimuli by unscrambling a series of
terminals running Qualtrics experimental software. Participants in word jumbles, or anagrams. Two practice items were first given to
Study 2 were provided with pencils, scratch paper, and a basic calcu- participants to familiarize them with the task. They were instructed to
lator. After signing an informed consent, participants completed cog- unscramble the letters presented to create a single word using all of the
nitive tasks, which varied by study and are described below. letters. For example, they were shown “obko,” which was unscrambled
Participants in Study 1 then completed measures related to a separate, to spell “book.” After participants completed each practice problem,
unrelated study on mate preferences. Next, all participants provided they were provided with the correct answer so that they could check
standard demographic information, as well as information regarding their work. Once the practice problems were complete, the software
HC use and duration, and completed attention checks. All participants displayed six word scrambles one at a time. The first three anagrams
were fully debriefed as to the hypotheses before being dismissed. were solvable: “gatmeemnna,” “rtnuatoas,” and “smcysagitn.” These
can be unscrambled to create the words “management,” “astronaut,”
1.2.1. Hormonal contraceptives and “gymnastics,” respectively. A performance score was computed by
To assess current HC use, participants responded to the following summing the number of correct responses, and perseverance on the
item: “Have you used any form of hormonal contraception within the solvable anagrams was measured by time spent on each problem. The
last 3 months?” If participants answered yes, they were asked to pro- unsolvable anagrams did not have a correct solution: “lnagpeatir,”
vide information regarding the type (e.g., pill, patch, skin implant, “loimcpris,” and “ircboeeyr.” Because they lack a solution, performance
hormonal IUD, etc.) and brand name (e.g., Mirena). Of the 163 women on the unsolvable anagrams could not be assessed. They were included
who indicated they were taking HCs across the studies, 138 women to assess perseverance on unsolvable tasks. For each type of word
provided information about the type of product they were using (see scramble, time spent was recorded via the timing function in Qualtrics.
Table 1 for more information). After providing this information, par- Perseverance measures for each type of word scramble (solvable and
ticipants indicated how many months they had been taking HCs and unsolvable) were created by averaging time spent across each word
whether they were on them currently. Participants were included in the scramble within each category.
HC condition if they were currently on a HC and had been for at least
two months prior to the time of the study (see “participants” section for 2. Results
information about exclusions).
2.1. Initial data processing
1.3. Cognitive tasks
Psychometric analysis performed prior to data analysis revealed
Participants in Study 1 completed a timed spot-the-difference task. positive skew for all of the outcome measures, with the exception of
In Study 2, participants completed both GRE quantitative problems and performance and perseverance on the GRE problems. To approximate
anagram problems. normal distributions, natural log 10 transformations were applied to the
positively skewed outcome measures before conducting analyses testing
1.3.1. Spot-the-difference task the hypotheses. Natural log 10 transformations successfully approxi-
In this task, participants were shown two seemingly identical mated normal distributions for all of the variables except performance
images side-by-side of the characters from Frozen, a popular animated and perseverance on the spot-the-difference task (Study 1) and per-
film (see supplemental materials for images). Although seemingly formance on the solvable anagrams task (Study 2). Original and
identical, the two images had 10 subtle differences. For example, in the transformed distributions of the dependent variables for each group can
image on the left, one of the characters had a snowflake levitating be seen in the supplemental materials. Due to this violation, non-
above her hand, and the snowman had two coal buttons, whereas these parametric Mann-Whitney U tests were used to examine the relation-
details were missing from the image on the right. Participants were ship between HC use and the dependent variables of perseverance and
instructed to find the differences between the left and the right images performance on the spot-the -difference task and performance on the
by clicking their mouse on the difference points in the right image. They solvable anagram task. See Table 1 for descriptive statistics. No outliers
were told that they could go to the next page whenever they wanted were found for perseverance (i.e., time spent) on the spot-the-difference
and were not told how many differences there were between the two task or the GRE quantitative task. Outliers on perseverance were found
pictures. Total time spent on this page was used as our measure of for both the solvable and unsolvable anagram tasks. However, given
perseverance. Task performance was measured using the number of that results persisted after outliers were removed from the data set, we
differences spotted. report the analyses on the full data set here. Results with outliers re-
moved can be found in the supplemental materials.
1.3.2. GRE quantitative problems
Prior to the GRE quantitative task, participants were informed that 2.2. Study 1
they were going to be asked some problem-solving questions. They
were instructed to select a single answer choice for each problem and 2.2.1. Spot-the-difference analyses
were told to feel free to use the calculator and paper provided when A Mann-Whitney U test indicated that naturally-cycling women
working on these problems. The software then displayed each of the spent significantly more time (Mdn = 81.51) than women taking HCs

3
H.K. Bradshaw, et al.

Table 1
Descriptive statistics for perseverance and performance during cognitive tasks as a function of HC use.
Spot-The-Difference Spot-The-Difference GRE Perseverance GRE Performance Solvable Anagram Solvable Anagram Unsolvable Anagram
Perseverance Performance Perseverance Performance Perseverance

M SD M SD M SD M SD M SD M SD M SD

Study 1
Naturally-cycling (n = 76) 84.62 41.08 5.57 2.84
HC (n = 73) 60.06 30.66 4.77 2.79
Method of HC administration
Constant dosage (n = 1) 52.43 6
Hormonal IUDs/skin implants 68.20 18.49 4.67 2.58
(n = 6)

4
Combination pill (n = 55) 70.94 32.68 4.96 2.87
Data missing (n = 11) 61.67 26.84 3.73 2.57
Study 2
Naturally-cycling (n = 86) 97.16 34.92 3.88 1.94 76.10 84.96 0.34 0.68 62.12 59.30
HC (n = 89) 78.54 28.50 3.21 1.89 44.14 41.24 0.18 0.44 38.55 39.23
Method of HC administration
Constant dosage (n = 4) 85.05 29.50 3.75 0.96 53.88 26.29 0 0 64.38 60.60
Hormonal IUDs/skin implants 82.09 15.37 2.86 2.19 55.21 45.91 0.29 0.49 61.51 53.89
(n = 7)
Nuva ring (n = 2) 83.26 15.10 5.50 3.54 77.42 43.10 0 0 60.36 57.12
Combination pill (n = 63) 75.27 28.10 3.14 1.92 44.35 44.03 0.17 0.46 30.75 30.31
Data missing (n = 13) 89.75 36.15 3.23 1.54 29.05 23.25 0.23 0.44 52.66 52.47

Note. Perseverance represents time spent in seconds. Performance represents number of correct responses.
Hormones and Behavior 119 (2020) 104652
H.K. Bradshaw, et al. Hormones and Behavior 119 (2020) 104652

(Mdn = 67.42) on the spot the difference task, U = 2142.00, problems, they also perform better.2
Z = −2.40, p = .02, r = 0.20. While not statistically significant, results
revealed a marginal effect of HC use on numbers of differences spotted, 2.3.2. Mediation of GRE performance by perseverance
where naturally-cycling women spotted a greater number of differences To examine whether perseverance on the GRE math problems
(Mdn = 6) than those who were using HCs (Mdn = 5), U = 2277.50, mediated performance on this task, a mediation analysis was conducted
Z = −1.90, p = .058, r = 0.16. These results suggest that, compared to as was done with the previous task. The analysis revealed a significant
naturally-cycling women, HC use is associated with less perseverance indirect effect of HC use on women's performance on GRE questions via
and marginally worse task performance.1 perseverance, b = 0.40, SE = 0.13, 95% CI [0.18, 0.67]. The model,
along with statistics measuring the significance of each predictive
2.2.2. Mediation of spot-the-difference performance by perseverance pathway, can be seen in Fig. 2. Naturally-cycling women spent sig-
To examine whether differences in women's performance on the nificantly more time on the GRE problems than HC users, (a path;
spot-the-difference task could be accounted for by differences in per- b = 18.62, SE = 4.81, t = 3.87, p ≤ .001, 95% CI [9.12, 28.12]), and
severance, a mediation analysis was conducted using the Preacher and increased time spent on the problems significantly predicted increased
Hayes' (2008) macro and bootstrapping procedure. Five thousand performance on the GRE questions, (b path; b = 0.02, SE = 0.004,
bootstrap resamples were performed. The analysis revealed a sig- t = 5.00, p ≤ .001, 95% CI [0.01, 0.03]). The effect of HC use on GRE
nificant indirect effect of HC use on women's performance on the spot- performance (c path; b = 0.67, SE = 0.29, t = 2.32, p = .022, 95% CI
the-difference task via time spent on the task, b = 0.77, SE = 0.29, 95% [0.10, 1.24]) disappeared after controlling for the mediating influence
CI [0.19, 1.33]. The model, along with statistics measuring the sig- of perseverance (c’ path; b = 0.27, SE = 0.28, t = 0.96, p = .34, 95%
nificance of each predictive pathway, can be seen in Fig. 1. Specifically, CI [−0.29, 0.83]), providing evidence that changes in perseverance
the results revealed that naturally-cycling women spent significantly mediated the relationship between HC use and performance on GRE
more time on the spot-the-difference task than HC women (a path; problems.
b = 15.56, SE = 5.96, t = 2.61, p = .010, 95% CI [3.78, 27.33]), and
that increased time spent on the spot-the-difference task predicted in- 2.3.3. Word scramble analyses
creased performance on the task, (b path; b = 0.05, SE = 0.005, Independent samples t-tests were conducted to compare persever-
t = 10.05, p ≤ .001, 95% CI [0.04, 0.06]). Moreover, the direct effect ance on the anagram problems in naturally-cycling women and women
revealed that the marginal effect of HC use on task performance (c path; taking HCs. Levene's test for equality of variances was met for the
b = 0.80, SE = 0.46, t = 1.73, p = .086, 95% CI [−0.11, 1.71]) solvable (p = .77) and unsolvable (p = .84) perseverance variables.
disappeared after controlling for the mediating influence of persever- Results revealed that naturally-cycling women (Mseconds = 76.11,
ance (c’ path; b = 0.03, SE = 0.36, t = 0.08, p = .940, 95% CI [−0.69, SDseconds = 84.95) spent significantly more time on the solvable ana-
0.75]). These results are consistent with partial mediation, suggesting grams than those taking HCs (Mseconds = 44.14, SDseconds = 41.24), t
that women using HCs exhibited decreased perseverance relative to (173) = −4.13, p ≤ .001, d = 0.48. The same pattern of results
naturally-cycling women, which led them to perform worse on the task. emerged for the unsolvable anagrams, where naturally-cycling women
(Mseconds = 62.12, SDseconds = 59.30) spent significantly spent more
2.2.3. Additional analyses time attempting to solve the unsolvable anagrams than women taking
To examine whether women in the HC group differed in their per- HCs (Mseconds = 38.55, SDseconds = 39.23), t(173) = −2.99, p = .003,
formance and persistence on the spot-the-difference task based on the d = 0.47. The Mann-Whitney U test performed on the task performance
method of HC administration (e.g., constant dosage, skin implant, variable (solvable word scrambles only) indicated no significant dif-
combination pill), Kruskal-Wallis tests were performed on each de- ference between naturally-cycling women (Mdn = 0) and women
pendent variable. No significant differences were revealed (ps ≥ 0.68), taking HCs (Mdn = 0), U = 3441.00, Z = −1.64, p = .10, r = 0.12.3
supporting our decision to treat women taking HCs as a unitary group.
2.3.4. Mediation of solvable word scramble performance by perseverance
2.3. Study 2 Consistent with the previous analyses, a mediation analysis was
conducted to examine if perseverance on the solvable anagrams medi-
2.3.1. GRE analyses ated performance. The analysis revealed a significant indirect effect of
Independent samples t-tests were conducted to compare persever-
ance and performance on the GRE problems in women taking HCs and
2
naturally-cycling women. Levene's test for equality of variances was ANCOVAs were conducted on the GRE performance and perseverance
met for the perseverance (p = .05) and performance (p = .76) GRE variables to examine whether the pattern of results would persist while con-
trolling for duration of HC use. Results indicated that the effect of HC use on
variables. Results revealed that naturally-cycling women
GRE problem performance and perseverance held while controlling for duration
(Mseconds = 97.16, SDseconds = 34.92) spent more time on GRE pro-
of HC use, F(1, 172) = 4.38, p = .04, partial ɳ2 = 0.03, and F(1, 172) = 6.54,
blems than women on HCs (Mseconds = 78.53, SDseconds = 28.50), t p = .01, partial ɳ2 = 0.04, respectively. As in Study 1, follow-up correlational
(173) = −3.87, p ≤ .001, d = 0.58. Further, results revealed that analyses were next conducted to examine whether duration of HC use impacted
naturally-cycling women (M = 3.88, SD = 1.94) correctly solved more performance and perseverance on the GRE problems for those taking HCs.
GRE problems than women taking HCs (M = 3.21, SD = 1.89), t Results indicated that there was no significant relationship between duration of
(173) = −2.32, p = .02, d = 0.35. These results indicate that natu- HC use and performance or perseverance on the GRE problems (ps = 0.65).
3
rally-cycling women not only exhibit more perseverance on GRE math ANCOVAs were conducted to examine whether the patterns of results would
persist while controlling for duration of HC use. The pattern of results persisted
for perseverance on the solvable and unsolvable anagrams while controlling for
1
Follow-up correlational analyses were performed to examine whether duration of HC use, F(1, 172) = 10.17, p = .002, partial ɳ2 = 0.06, and F(1,
duration of HC use was related to performance and perseverance on the spot- 172) = 4.28, p = .04, partial ɳ2 = 0.02, respectively. When controlling for
the-difference task for women who were taking HCs. No significant relationship duration of HC use, the effect of HCs on unsolvable anagram performance re-
between duration of HC use and performance (p = .72) or perseverance (p = mained nonsignificant, F(1, 172) = 2.09, p = .15. As we did with the GRE
.28) was found. Analyses of covariance (ANCOVA) conducted on the spot-the- items, we conducted follow-up correlational analyses to examine whether
difference performance and perseverance variables revealed that, while con- duration of HC use impacted performance and perseverance on the anagram
trolling for duration of HC use, the pattern of results persisted (spot-the-dif- problems for those taking HCs revealed that there was no significant relation-
ference performance: F[1, 146] = 2.80, p = .097, partial ɳ2 = 0.02; spot-the- ship between duration of HC use and perseverance or performance or on the
difference perseverance: F[1, 146] = 7.39, p = .007, partial ɳ2 = 0.05). anagram problems (ps ≥ 0.65).

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H.K. Bradshaw, et al. Hormones and Behavior 119 (2020) 104652

Fig. 1. Study 1 unstandardized regression coefficients for the relationship between HC use and performance on the spot-the-difference task as mediated by perse-
verance on the task.
Note: † indicates p = .09, * indicates p < .05, ** indicates p ≤ .01, and *** indicates p ≤ .001.

Fig. 2. Study 2 unstandardized regression coefficients for the relationship between HC use and performance on the GRE task as mediated by perseverance on the task.
Note: * indicates p < .05, ** indicates p ≤ .01, and *** indicates p ≤ .001.

Fig. 3. Study 2 unstandardized regression coefficients for the relationship between HC use and performance on the solvable anagram task as mediated by perse-
verance on the task.
Note: † indicates p = .08, * indicates p < .05, ** indicates p ≤ .01, and *** indicates p ≤ .001.

HC use on women's performance on the solvable anagram questions via 0.07]). These results provide evidence of partial mediation, consistent
perseverance, b = 0.01, SE = 0.01, 95% CI [0.004, 0.03]. The model, with the hypothesis that HC use predicts worse task performance
along with statistics measuring the significance of each predictive through its mediating influence on perseverance.
pathway, can be seen in Fig. 3. Naturally-cycling women spent sig-
nificantly more time on the solvable word scrambles (a path; b = 0.23,
SE = 0.06, t = 4.13, p ≤ .001, 95% CI [0.12, 0.34]), and time spent on 2.3.5. Additional analyses
the problems predicted slightly better performance, (b path; b = 0.07, To examine whether women in the HC group differed in their per-
SE = 0.03, t = 2.22, p = .03, 95% CI [0.01, 0.12]). While not statis- formance and persistence on the GRE and word scramble tasks based on
tically significant, results revealed a marginal total effect of HC use on the method of HC administration (e.g., constant dosage, skin implant,
solvable anagram performance (c path; b = 0.04, SE = 0.02, t = 1.76, combination pill), Kruskal-Wallis tests were performed on each de-
p = .080, 95% CI [−0.005, 0.08]). The direct effect revealed that the pendent variable. No significant differences were revealed (ps ≥ 0.19),
marginal effect of HC use on solvable anagram performance dis- supporting our decision to treat women taking HCs as a unitary group.
appeared after controlling for the mediating influence of perseverance
(c’ path; b = 0.02, SE = 0.02, t = 1.04, p = .30, 95% CI [−0.02,

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H.K. Bradshaw, et al. Hormones and Behavior 119 (2020) 104652

3. Summary of results perseverance on GRE math problems than did naturally-cycling women,
and that these differences led to worse performance. Given that many
The results of Study 1 found that naturally-cycling women exhibited women who use HCs are in their late teens and twenties (which is when
more perseverance, which lead to better performance on a simple vi- most people take standardized tests such as the SAT, GRE, and LSAT),
suospatial task when compared to women taking HCs. These results HCs could possibly make it more challenging for women to meet their
were conceptually replicated and extended in Study 2, with results higher education goals. Moreover, given that HC use is increasing
revealing that naturally-cycling women spent more time, which lead to among adolescents (Rashed et al., 2015), young girls taking HCs in
better performance on GRE quantitative problems and solvable ana- middle school and high school may also struggle with cognitive control
grams than women taking HCs. Further, naturally-cycling women also of learning and persisting through cognitive tasks, which could possibly
persisted longer on unsolvable anagrams than did women taking HCs. impact their later career options. This interpretation is consistent with
recent research implicating HC use as a predictor of academic problems
4. Discussion in younger users (Gregory et al., 2018). Further research is needed to
investigate whether taking HCs at a young age corresponds to greater
Across two studies, we tested whether HC use is associated with morphological changes in the brain regions involved in executive
decrements in perseverance and performance on both simple and function and cognitive control of learning than is seen in young adult
challenging cognitive tasks. We found that women taking HCs (vs. women taking HCs. It is, however, important to note that HC use can
naturally-cycling women) spent less time on both simple (Study 1) and also aid in women's educational attainment by allowing them to pre-
challenging (Study 2) cognitive tasks. While women taking HCs per- vent unintended pregnancies, which can be an insurmountable barrier
formed worse than naturally-cycling women only on the GRE problems for those who wish to further their education. Highlighting this, women
(Study 2), HC-associated differences in perseverance predicted perfor- with a college degree report fewer unintended pregnancies than those
mance decrements across all tasks in both studies. That is, women without an advanced degree, and the highest rates of unintended
taking HCs performed worse than naturally-cycling women because pregnancies are found in women without a high school degree (Finer
they spent less time on the tasks. These results suggest that HC use may and Zolna, 2014). Further research examining the unintended con-
affect women's perseverance on simple and challenging tasks, which in sequences of HC use is vital to ensure that women are informed about
turn impacts task performance. the potential costs and benefits of using HCs at different points in their
Together, these results are consistent with recent research demon- lives.
strating that women taking HCs respond more quickly than naturally- While the results of the current research contribute to the literature
cycling women during mental-rotation tasks, which contributed to their on how HCs influence women's performance on cognitive tasks, it is not
diminished performance on the tasks (Griksiene et al., 2018). Further, without limitations. One important limitation arises from the cross-
the results of the current study also support the brain imaging research sectional nature of the current investigation. Because women were not
suggesting that HC use is associated with structural and functional randomly assigned to testing conditions (HC users versus natural cy-
differences in brain regions that play a key role in executive function clers), it is possible that the results of the current research may have
and the cognitive control of behavior (Hertel et al., 2017; Lisofsky et al., emerged due to pre-existing differences between women based on their
2016; Petersen et al., 2014; Petersen et al., 2015; Pletzer et al., 2016; HC use. For instance, naturally-cycling women may be more con-
Rueda et al., 2004; Wagner et al., 2001). While the current studies were scientious than HC users, as they may feel a greater need to be careful,
not designed to uncover the mechanism driving the relationship be- given their higher conception probability. Given that conscientiousness
tween HC use and decreased perseverance and/or performance on is closely related to self-control (MacCann et al., 2009; Roberts et al.,
cognitive tasks, it is possible that decreased resting state functional 2005) and self-regulation (Ivcevic and Brackett, 2014; Sansone et al.,
connectivity in the brain's executive control network and decreased 1999), it is possible that such pre-existing differences could account for
cortical thickness in the lateral orbitofrontal cortex and the posterior the current results. Although recent research suggests that there are no
cingulate cortex, both of which are found in HC users, could be driving differences in personality characteristics of users versus non-users
these results. Additionally, estrogen levels, which are generally lower (Beltz et al., 2019), which detracts from this alternative explanation,
for HC users than for women who are naturally-cycling (for most of experimental work is needed before a conclusive cause and effect re-
their ovulatory cycle), are found to play a key role in hippocampal lationship between HC use and perseverance on simple and difficult
function. Spencer et al. (2008) find that estrogen influences cell mor- cognitive tasks can be established.
phology, synapse formation, signaling, and excitability in the hippo- Another limitation is that the current research investigated the
campus. Other researchers find that estrogen enhances synaptic plas- differences between women who were naturally-cycling and women
ticity and improves performance on hippocampal-dependent cognitive taking HCs without considering the different types of progestins in the
tasks (e.g. Brann et al., 2007; Li et al., 2004; Luine et al., 2003). While HCs used by the women in the study. These differences may have im-
the majority of the work investigating the effects of estrogen on hip- portant implications for women's cognition and behavior. For instance,
pocampal function has been done in rodents, it could be that decreases first and second generation HCs are more androgenic than third gen-
in estrogen levels exhibited by women using HCs may impact the hip- eration HCs, while fourth generation HCs are anti-androgenic (Davtyan,
pocampus in such a way that impairs perseverance and performance on 2012). As such, it is possible that the hormonal profiles of HCs may
cognitive tasks. While additional research in humans is needed to differentially impact the structural and functional changes observed in
evaluate these possible mechanisms, the current results provide com- the brain, changing their effect on women's cognition and behavior. For
pelling evidence that differences in perseverance during cognitive tasks instance, third generation HC users are found to spend more time on
exist between women who take HCs and those that are naturally-cy- mental-rotation tasks than naturally-cycling women (Griksiene and
cling, which can lead to decrements in performance, and that these Ruksenas, 2011), while fourth generation HC users are found to spend
differences warrant further investigation. less time (Griksiene et al., 2018). Additionally, we did not collect in-
The current research contributes to a growing body of work ex- formation about naturally-cycling women's history of HC use beyond
amining the implications of HC use on cognition, learning, and memory the last three months. History of HC use across the lifespan may be an
(Egan and Gleason, 2012; Griksiene et al., 2018; Griksiene and important factor to consider in future research. Moreover, the current
Ruksenas, 2011; Mordecai et al., 2008; Wright Jr and Badia, 1999). Our research did not include any measurement of sex hormones, which
results suggest that HC use may be associated with decreases in wo- would have allowed us to ask more specific mechanistic questions (e.g.,
men's ability to exercise cognitive control during problem solving. More what is the hormonal mechanism driving the relationship between HCs
specifically, our results find that women taking HCs exhibited less and perseverance). Accordingly, future studies should explore the

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H.K. Bradshaw, et al. Hormones and Behavior 119 (2020) 104652

possibility that the differing hormonal profiles of HCs may impact fields – from medicine to military to education – further research ex-
women's cognitive performance and perseverance in disparate ways. amining the role of HC use in perseverance are crucial to understanding
Further, it is possible that the differences reported here may have been how HC use may impact women's education, careers, and wellbeing.
greater between HC and naturally-cycling women in a certain phase of
the cycle, but, unfortunately, this possibility could not be addressed in Appendix A. Supplementary data
the current research.
A third limitation to consider is the limited number of cognitive Supplementary data to this article can be found online at https://
tasks utilized in the current research. By only assessing perseverance doi.org/10.1016/j.yhbeh.2019.104652.
and performance on one task in Study 1 (one spot-the-difference pic-
ture), and two tasks in Study 2 (three solvable word scrambles and eight References
GRE quantitative problems), we are unable to identify if specific types
of tasks are more likely to elicit differences in perseverance and per- Axmacher, N., Mormann, F., Fernández, G., Cohen, M.X., Elger, C.E., Fell, J., 2007.
formance than others. Moreover, only the GRE quantitative problems Sustained neural activity patterns during working memory in the human medial
temporal lobe. J. Neurosci. 27 (29), 7807–7816.
task revealed a statistically significant difference in performance be- Beltz, A.M., Hampson, E., Berenbaum, S.A., 2015. Oral contraceptives and cognition: A
tween naturally-cycling women and women taking HCs. This may be role for ethinyl estradiol. Horm. Behav. 74, 209–217.
because a greater number of stimuli/items were used in this task than Beltz, A.M., Loviska, A.M., Kelly, D., 2019. No personality differences between oral
contraceptive users and naturally cycling women: implications for research on sex
were used in the others, producing more variability. It could be that hormones. Psychoneuroendocrinology 100, 127–130.
significant differences in performance on the spot-the-difference and Beral, V., Doll, R., Hermon, C., Peto, R., Reeves, G., 2008. Ovarian cancer and oral
the solvable word scramble tasks would have been revealed if a greater contraceptives: collaborative reanalysis of data from 45 epidemiological studies in-
cluding 23257 women with ovarian cancer and 87303 controls. Lancet 371 (9609),
number of stimuli/items were included. This possibility should be
303–314.
considered in future research. Although there was no significant direct Brann, D.W., Dhandapani, K., Wakade, C., Mahesh, V.B., Khan, M.M., 2007. Neurotrophic
association between HC use and performance on the spot-the-difference and neuroprotective actions of estrogen: basic mechanisms and clinical implications.
Steroids 72 (5), 381–405.
task (Study 1) and the solvable word scramble task (Study 2), we found
Burkman, R., Schlesselman, J.J., Zieman, M., 2004. Safety concerns and health benefits
that differences in perseverance served as a mediator for the relation- associated with oral contraception. Am. J. Obstet. Gynecol. 190 (4), S5–S22.
ship between HC use and performance on all tasks. This is most likely Cragg, L., Gilmore, C., 2014. Skills underlying mathematics: the role of executive function
due to the relationship between perseverance and performance on tasks in the development of mathematics proficiency. Trends in Neuroscience and
Education 3 (2), 63–68.
(i.e., time spent on tasks predicts better performance; Galla et al., Cragg, L., Keeble, S., Richardson, S., Roome, H.E., Gilmore, C., 2017. Direct and indirect
2014). This result could further suggest that the relationship between influences of executive functions on mathematics achievement. Cognition 162,
perseverance and task performance is likely driven by a number of 12–26.
Credé, M., Tynan, M.C., Harms, P.D., 2017. Much ado about grit: a meta-analytic
precipitating factors, including – but not limited to – HC use. synthesis of the grit literature. J. Pers. Soc. Psychol. 113 (3), 492.
Additionally, the data for two of the three tasks were non-normally Davtyan, C., 2012. Four generations of progestins in oral contraceptives. Proceedings of
distributed. Again, this is likely due to the small number of stimuli/ UCLA Healthcare 16, 1–3.
Duckworth, A.L., Peterson, C., Matthews, M.D., Kelly, D.R., 2007. Grit: perseverance and
items included in the current research, and future research would passion for long-term goals. J. Pers. Soc. Psychol. 92 (6), 1087.
benefit from utilizing additional tasks consisting of a larger number of Egan, K.R., Gleason, C.E., 2012. Longer duration of hormonal contraceptive use predicts
stimuli per task. Finally, although we did not conduct a priori power better cognitive outcomes later in life. J. Women’s Health 21 (12), 1259–1266.
Eisenberger, R., Leonard, J.M., 1980. Effects of conceptual task difficulty on generalized
analyses to determine appropriate sample size, post hoc power analyses persistence. Am. J. Psychol. 285–298.
conducted using the effect size from the perseverance dependent vari- Engelman, P., 2001. McCormick, Katharine Dexter. In: Bullough, V.L. (Ed.), Encyclopedia
able in the current research revealed that power for Study 1 was at of Birth Control. ABC-CLIO, Santa Barbara, CA, pp. 169–171.
Finer, L.B., Zolna, M.R., 2014. Shifts in intended and unintended pregnancies in the
0.74, and power for Study 2 was at 0.87. As such, our studies were
United States, 2001–2008. Am. J. Public Health 104 (S1), S43–S48.
adequately powered to detect the predicted effects. Finn, A.S., Kraft, M.A., West, M.R., Leonard, J.A., Bish, C.E., Martin, R.E., Sheridan, M.A.,
Despite these limitations, the current research poses as an important Gabrieli, C.F.O., Gabrieli, J.D., 2014. Cognitive skills, student achievement tests, and
contribution to the growing body of literature examining how HC use schools. Psychol. Sci. 25 (3), 736–744.
Frodl, T., Schaub, A., Banac, S., Charypar, M., Jäger, M., Kümmler, P., Bottlender, R.,
influences women's cognitive performance. While other researchers Zetzsche, T., Born, C., Leinsinger, G., Reiser, M., Möller, H., Meisenzahl, E.M., 2006.
have targeted performance on cognitive tasks as their primary outcome, Reduced hippocampal volume correlates with executive dysfunctioning in major
the current research was designed to uncover differences in persever- depression. J. Psychiatry Neurosci. 31 (5), 316.
Fukuba, E., Kitagaki, H., Wada, A., Uchida, K., Hara, S., Hayashi, T., Oda, K., Uchida, N.,
ance on cognitive tasks, which was found, as predicted, to lead to dif- 2009. Brain activation during the spot the differences game. Magn. Reson. Med. Sci. 8
ferences in performance. These results add to a growing body of lit- (1), 23–32.
erature demonstrating the far-reaching, and often unanticipated, effects Galla, B.M., Plummer, B.D., White, R.E., Meketon, D., D’Mello, S.K., Duckworth, A.L.,
2014. The Academic Diligence Task (ADT): assessing individual differences in effort
of taking HCs (see e.g., Gregory et al., 2018; Hertel et al., 2017; on tedious but important schoolwork. Contemp. Educ. Psychol. 39 (4), 314–325.
Rohleder et al., 2003; Welling, 2013; Zethraeus et al., 2017). Such in- Gilhooly, K.J., Fioratou, E., 2009. Executive functions in insight versus non-insight pro-
formation is critical for women hoping to make informed decisions blem solving: an individual differences approach. Think. Reason. 15 (4), 355–376.
Gould, E., Tanapat, P., 1999. Stress and hippocampal neurogenesis. Biol. Psychiatry 46
about HC use and for scientists seeking to better understand the psy- (11), 1472–1479.
chological impact of HCs. Gray, J.A., McNaughton, N., 1983. Comparison between the behavioural effects of septal
and hippocampal lesions: a review. Neurosci. Biobehav. Rev. 7 (2), 119–188.
Gregory, S.T., Hall, K., Quast, T., Gatto, A., Bleck, J., Storch, E.A., DeBate, R., 2018.
5. Conclusion
Hormonal contraception, depression, and academic performance among females at-
tending college in the United States. Psychiatry Res. 270, 111–116.
While HCs have allowed women to take control of their fertility, it is Griksiene, R., Ruksenas, O., 2011. Effects of hormonal contraceptives on mental rotation
nevertheless important to consider the unintended outcomes associated and verbal fluency. Psychoneuroendocrinology 36 (8), 1239–1248.
Griksiene, R., Monciunskaite, R., Arnatkeviciute, A., Ruksenas, O., 2018. Does the use of
with HC use. For instance, a growing body of research suggests that hormonal contraceptives affect the mental rotation performance? Horm. Behav. 100,
women who take HCs may experience important structural and func- 29–38.
tional changes in brain areas that regulate learning and task perfor- Hertel, J., König, J., Homuth, G., Auwera, S., Wittfeld, K., Pietzner, M., Kacprowski, T.,
Pfeiffer, L., Kretschmer, A., Waldenberger, M., Kastenmüller, G., Artati, A., Suhre, K.,
mance. Here, we demonstrate that, compared to naturally-cycling Adamski, J., Sönke, L., Völker, U., Völzke, H., Nauck, M., Friedrich, N., Grabe, H.J.,
women, women taking HCs display less perseverance on both simple 2017. Evidence for stress-like alterations in the HPA-axis in women taking oral
and cognitively taxing tasks. Given that perseverance is highly pre- contraceptives. Sci. Rep. 7 (1), 14111.
Islam, F., Sparkes, C., Roodenrys, S., Astheimer, L., 2008. Short-term changes in en-
dictive of success across many areas of life, including learning, educa- dogenous estrogen levels and consumption of soy isoflavones affect working and
tional attainment, work performance, and career success in a variety of

8
H.K. Bradshaw, et al. Hormones and Behavior 119 (2020) 104652

verbal memory in young adult females. Nutr. Neurosci. 11 (6), 251–262. Psychol. Meas. 53 (3), 801–813.
Ivcevic, Z., Brackett, M., 2014. Predicting school success: comparing conscientiousness, Pletzer, B.A., Kerschbaum, H.H., 2014. 50 years of hormonal contraception—time to find
grit, and emotion regulation ability. J. Res. Pers. 52, 29–36. out, what it does to our brain. Front. Neurosci. 8, 256.
Jones, R.K., 2011. Beyond Birth Control: The Overlooked Benefits of Oral Contraceptive Pletzer, B., Crone, J.S., Kronbichler, M., Kerschbaum, H., 2016. Menstrual cycle and
Pills. Guttmacher Institute, New York, NY. hormonal contraceptive-dependent changes in intrinsic connectivity of resting-state
Kahlenborn, C., Modugno, F., Potter, D.M., Severs, W.B., 2006. Oral contraceptive use as a brain networks correspond to behavioral changes due to hormonal status. Brain
risk factor for premenopausal breast cancer: a meta-analysis. In: Mayo Clinic Connectivity 6 (7), 572–585.
Proceedings (Vol. 81, No. 10, pp. 1290–1302). Elsevier. Preacher, K.J., Hayes, A.F., 2008. Asymptotic and resampling strategies for assessing and
Kavanaugh, M.L., Jerman, J., 2018. Contraceptive method use in the United States: trends comparing indirect effects in multiple mediator models. Behav. Res. Methods 40 (3),
and characteristics between 2008, 2012 and 2014. Contraception 97 (1), 14–21. 879–891.
Kirschbaum, C., Kudielka, B.M., Gaab, J., Schommer, N.C., Hellhammer, D.H., 1999. Rashed, A.N., Hsia, Y., Wilton, L., Ziller, M., Kostev, K., Tomlin, S., 2015. Trends and
Impact of gender, menstrual cycle phase, and oral contraceptives on the activity of patterns of hormonal contraceptive prescribing for adolescents in primary care in the
the hypothalamus-pituitary-adrenal axis. Psychosom. Med. 61 (2), 154–162. UK. J Fam Plann Reprod Health Care 41 (3), 216–222.
Kreplin, U., Fairclough, S.H., 2013. Activation of the rostromedial prefrontal cortex Rawlins, J.N.P., Tsaltas, E., 1983. The hippocampus, time and working memory. Behav.
during the experience of positive emotion in the context of esthetic experience. An Brain Res. 10 (2–3), 233–262.
fNIRS study. Frontiers in Human Neuroscience 7, 879. Roberts, B.W., Chernyshenko, O.S., Stark, S., Goldberg, L.R., 2005. The structure of
Kroll, M.D., 1991. Persistence following differential failure. The Journal of Psychology conscientiousness: an empirical investigation based on seven major personality
125 (2), 241–251. questionnaires. Pers. Psychol. 58 (1), 103–139.
Lee, A.C., Barense, M.D., Graham, K.S., 2005. The contribution of the human medial Robertson-Kraft, C., Duckworth, A.L., 2014. True grit: trait-level perseverance and pas-
temporal lobe to perception: bridging the gap between animal and human studies. sion for long-term goals predicts effectiveness and retention among novice teachers.
The Quarterly Journal of Experimental Psychology Section B 58 (3–4), 300–325. Teachers College Record (1970) 116 (3).
Li, C., Brake, W.G., Romeo, R.D., Dunlop, J.C., Gordon, M., Buzescu, R., Magarinos, A.M., Rohleder, N., Wolf, J.M., Piel, M., Kirschbaum, C., 2003. Impact of oral contraceptive use
Allen, P.B., Greengard, P., Luine, V., McEwen, B.S., 2004. Estrogen alters hippo- on glucocorticoid sensitivity of pro-inflammatory cytokine production after psycho-
campal dendritic spine shape and enhances synaptic protein immunoreactivity and social stress. Psychoneuroendocrinology 28 (3), 261–273.
spatial memory in female mice. Proc. Natl. Acad. Sci. 101 (7), 2185–2190. Rueda, M.R., Posner, M.I., Rothbart, M.K., 2004. Attentional control and self-regulation.
Lidegaard, Ø., Løkkegaard, E., Jensen, A., Skovlund, C.W., Keiding, N., 2012. Thrombotic Handbook of Self-Regulation: Research, Theory, and Applications 2, 284–299.
stroke and myocardial infarction with hormonal contraception. N. Engl. J. Med. 366 Salles, A., Cohen, G.L., Mueller, C.M., 2014. The relationship between grit and resident
(24), 2257–2266. well-being. Am. J. Surg. 207 (2), 251–254.
Lisofsky, N., Riediger, M., Gallinat, J., Lindenberger, U., Kühn, S., 2016. Hormonal Sansone, C., Wiebe, D.J., Morgan, C., 1999. Self-regulating interest: the moderating role
contraceptive use is associated with neural and affective changes in healthy young of hardiness and conscientiousness. J. Pers. 67 (4), 701–733.
women. Neuroimage 134, 597–606. Sapolsky, R.M., Krey, L.C., McEwen, B.S., 1985. Prolonged glucocorticoid exposure re-
Littman-Ovadia, H., Lavy, S., 2016. Going the extra mile: perseverance as a key character duces hippocampal neuron number: implications for aging. J. Neurosci. 5 (5),
strength at work. Journal of Career Assessment 24 (2), 240–252. 1222–1227.
Luine, V.N., Jacome, L.F., MacLusky, N.J., 2003. Rapid enhancement of visual and place Spencer, J.L., Waters, E.M., Romeo, R.D., Wood, G.E., Milner, T.A., McEwen, B.S., 2008.
memory by estrogens in rats. Endocrinology 144 (7), 2836–2844. Uncovering the mechanisms of estrogen effects on hippocampal function. Front.
MacCann, C., Duckworth, A.L., Roberts, R.D., 2009. Empirical identification of the major Neuroendocrinol. 29 (2), 219–237.
facets of conscientiousness. Learn. Individ. Differ. 19 (4), 451–458. Ventura, M., Shute, V., Zhao, W., 2013. The relationship between video game use and a
Meck, W.H., Church, R.M., Olton, D.S., 1984. Hippocampus, time, and memory. Behav. performance-based measure of persistence. Comput. Educ. 60 (1), 52–58.
Neurosci. 98 (1), 3–22. Wagner, A.D., Maril, A., Bjork, R.A., Schacter, D.L., 2001. Prefrontal contributions to
Mendelsohn, G.A., Griswold, B.B., Anderson, M.L., 1966. Individual differences in ana- executive control: fMRI evidence for functional distinctions within lateral prefrontal
gram-solving ability. Psychol. Rep. 19 (3), 799–809. cortex. Neuroimage 14 (6), 1337–1347.
Montoya, E.R., Bos, P.A., 2017. How oral contraceptives impact social-emotional beha- Warren, A.M., Gurvich, C., Worsley, R., Kulkarni, J., 2014. A systematic review of the
vior and brain function. Trends Cogn. Sci. 21 (2), 125–136. impact of oral contraceptives on cognition. Contraception 90 (2), 111–116.
Mordecai, K.L., Rubin, L.H., Maki, P.M., 2008. Effects of menstrual cycle phase and oral Welling, L.L., 2013. Psychobehavioral effects of hormonal contraceptive use. Evol.
contraceptive use on verbal memory. Horm. Behav. 54 (2), 286–293. Psychol. 11 (3), 147470491301100315.
Muenks, K., Wigfield, A., Yang, J.S., O’Neal, C.R., 2017. How true is grit? Assessing its Wharton, W., Hirshman, E., Merritt, P., Doyle, L., Paris, S., 2008. Oral contraceptives and
relations to high school and college students’ personality characteristics, self-reg- androgenicity: Influences on visuospatial task performance in younger individuals.
ulation, engagement, and achievement. J. Educ. Psychol. 109 (5), 599. Exp. Clin. Psychopharmacol. 16 (2), 156.
Nishiguchi, S., Yamada, M., Fukutani, N., Adachi, D., Tashiro, Y., Hotta, T., Morino, S., Woolley, C.S., Gould, E., McEwen, B.S., 1990. Exposure to excess glucocorticoids alters
Aoyama, T., Tsuboyama, T., 2015. Spot the difference for cognitive decline: a quick dendritic morphology of adult hippocampal pyramidal neurons. Brain Res. 531 (1–2),
memory and attention test for screening cognitive decline. Journal of Clinical 225–231.
Gerontology and Geriatrics 6 (1), 9–14. Wright Jr., K.P., Badia, P., 1999. Effects of menstrual cycle phase and oral contraceptives
Novick, L.R., Sherman, S.J., 2003. On the nature of insight solutions: evidence from skill on alertness, cognitive performance, and circadian rhythms during sleep deprivation.
differences in anagram solution. The Quarterly Journal of Experimental Psychology Behav. Brain Res. 103 (2), 185–194.
Section A 56 (2), 351–382. Wuttke, W., Arnold, P., Becker, D., Creutzfeldt, O., Langenstein, S., Tirsch, W., 1975.
Petersen, N., Kilpatrick, L.A., Goharzad, A., Cahill, L., 2014. Oral contraceptive pill use Circulating hormones, EEG, and performance in psychological tests of women with
and menstrual cycle phase are associated with altered resting state functional con- and without oral contraceptives. Psychoneuroendocrinology 1 (2), 141–152.
nectivity. Neuroimage 90, 24–32. Zethraeus, N., Dreber, A., Ranehill, E., Blomberg, L., Labrie, F., von Schoultz, B.,
Petersen, N., Touroutoglou, A., Andreano, J.M., Cahill, L., 2015. Oral contraceptive pill Jonannesson, M., Hirschberg, A.L., 2017. A first-choice combined oral contraceptive
use is associated with localized decreases in cortical thickness. Hum. Brain Mapp. 36 influences general well-being in healthy women: a double-blind, randomized, pla-
(7), 2644–2654. cebo-controlled trial. Fertil. Steril. 107 (5), 1238–1245.
Pintrich, P.R., Smith, D.A., Garcia, T., McKeachie, W.J., 1993. Reliability and predictive Zimmerman, B.J., Pons, M.M., 1986. Development of a structured interview for assessing
validity of the Motivated Strategies for Learning Questionnaire (MSLQ). Educ. student use of self-regulated learning strategies. Am. Educ. Res. J. 23 (4), 614–628.