The D-MER Book


Before the Letdown: Dysphoric Milk Ejection Reflex and the Breastfeeding Mother

Before The Letdown holds information for mothers looking for support and understanding, for care providers who want to know how to best support their patients and for partners and family members who want to know how to best support a mother with D-MER. Dysphoric milk ejection treatment options and suggestions for D-MER treatment are included with appropriate references. There is also a chapter that includes mother's personal stories. Learn what can make D-MER worse and learn answers to the most commonly asked questions about dysphoric milk ejection reflex.

The book is written by Alia Macrina Heise, IBCLC who has been the forerunner in discovering and identifying D-MER since 2007. It includes a preface by internationally renowned lactation author and presenter, Diane Wiessinger, MS, IBCLC and is edited by Dr. Marcelina Watkinson, DClinPsy who did the first qualitative research study on D-MER.

What is Dysphoric Milk Ejection Reflex?


Dysphoric Milk Ejection Reflex is a condition affecting lactating women that is characterized by an abrupt dysphoria, or negative emotions, that occur just before milk release and continuing not more than a few minutes.

D-MER is often found through Google searches such as "breastfeeding problems" or "sadness when breastfeeding". Information about D-MER is expanding through awareness and increased online content.

Preliminary anecdotal evidence shows that D-MER is treatable if severe and preliminary investigation shows that inappropriate dopamine activity at the time of the milk ejection reflex is the cause of D-MER.

Dysphoria is defined as an unpleasant or uncomfortable mood, such as sadness, depressed mood, anxiety, irritability, or restlessness. Etymologically, it is the opposite of euphoria.

D-MER is like a reflex. It is controlled by hormones and can not be controlled by the mother. She can not talk herself out of the dysphoria.

What D-MER is Not

D-MER is not a psychological response to breastfeeding. It is a physiological response to milk release.

D-MER is not nausea with letdown or any other isolated physical symptom or manifestation. D-MER has a negative emotional component above all else.

D-MER is not postpartum depression nor is it classified as a postpartum mood disorder.

D-MER is not a general dislike of breastfeeding.  Impatience with baby at the breast, irritability from nipple pain, sadness during pumping because of separation from the baby; these things are not D-MER.

D-MER is not the "breastfeeding aversion" that can happen to some mothers when nursing while pregnant or when nursing older toddlers.

Characteristics of D-MER

The dysphoria a mother feels comes on suddenly before letdown and leaves within 30 seconds to 2 minutes. 

She feels the dysphoria before she feels the letdown sensation in her breasts (though not all mothers feel a physical letdown sensation). 

Often by the end of the first letdown she feels fine again, the dysphoria is gone.

It can happen for the first letdown of a feeding or for all letdowns in a feeding, depending on the intensity of her D-MER.

She may or may not have dysphoria with letdowns when pumping and before spontaneous letdowns, this also is dependent of the intensity of her D-MER.

D-MER has nothing to do with nipple contact or with irritation with the sensation of nipple tugging. The mother does not even have to be thinking about breastfeeding (for example with spontaneous letdowns) for the dysphoria to happen when a milk release is triggered.

Dopamine's Role in D-MER

D-MER has been linked to an inappropriate drop in dopamine that occurs whenever milk is released. In a mother with D-MER at the time of letdown dopamine falls inappropriately, causing negative feelings. 

Milk release itself isn't caused by dopamine dropping; it's caused by oxytocin rising. In D-MER, the MER (milk ejection reflex) is a result of rising oxytocin (needed to move the milk out of the breast) but the D (dysphoria) is a result of inappropriately falling dopamine. Dopamine gets involved because it inhibits prolactin (which is what makes the milk) so dopamine levels need to drop for prolactin levels to rise in order to make more milk. Normally, dopamine drops properly and breastfeeding mothers never knew it even happened, in D-MER mothers however, it doesn't drop properly and causes an instant and brief wave of  a negative emotional reaction that lasts until the dopamine levels restabilize after prolactin has begun it's rise. 

D-MER follows the same pattern as any other reflex. You can tell yourself your knee isn't going to jerk when you hit it... but it does, just as much the hundredth time as it does the first, and it stops as soon as the stimulus stops. The D-MER reflex involves e-motion rather than motion because a hormone shift is triggered instead of having a muscle nerve triggered.

Spectrum and Intensity

The experience of D-MER is variable and a mother will have either despondency D-MER, anxiety D-MER or agitation D-MER. Her dysphoria will fall on it's own place on the emotional spectrum, ranging from homesickness (mild despondency D-MER) to anger (severe agitation D-MER.)

The D-MER experience is variable. Because of this D-MER is defined on a spectrum. 

Think of a color spectrum; red is not the same as blue, even though they are both colors. Like this, D-MER can present with different "colors" of emotion for different mothers; despondency, anxiety or anger. 

There are three intensities of D-MER that included mild, moderate and severe. These intensities are determined by the mother's interpretation of intensity, how long the D-MER takes to self correct, how many letdowns per feeding she feels the dysphoria and other criteria. 

Mild often self correct in the first 3 month, moderate by month 9 and severe sometimes does not correct until after the first year or later.

Correction of D-MER

For mothers with mild D-MER, education goes a long way in treatment. Many find their symptoms more easily managed once they are aware it is a medical problem not an emotional problem. 

Moderate D-MER can also be reduced using education as treatment.  If this is not enough than these mothers should be encouraged  to track their D-MER  in a log to help them become aware of things  that may aggravate  their symptoms (stress, dehydration, caffeine) and things that may help relieve the symptoms (extra rest, better hydration, exercise.) They should look into lifestyle changes and natural remedies to help them further.

Mothers with more severe D-MER may need a prescription in order to manage her D-MER if she feels she may wean because of it. Thus far, treatments that increase dopamine levels in a mother treat D-MER effectively. If her D-MER is severe, and yet she is not at risk for weaning then using education as treatment, natural remedies and lifestyle changes is the more appropriate course of action.


Alia Macrina Heise, IBCLC is managed by the lactation consultant that first identified D-MER in 2007. She, herself, was a sufferer of D-MER while breastfeeding her third child. Alia is now an international speaker and published writer on the topic.

Goals and Mission is a web platform dedicated to the education and awareness of dysphoric milk ejection reflex. The evidenced-based information about D-MER is still limited but anecdotal evidence about the manifestation and treatment of D-MER has been sourced from the thousands of women who have shared their experiences. Meanwhile, research continues to progress and expand on the phenomenon as it's acceptance has a very secure place in the knowledge base of human lactation now. It is the hope that information will continue to spread and that the knowledge base about D-MER will expand as more research and investigation is done.


The information on the site should not be taken as medical advice. A health care professional should be consulted about any breastfeeding concerns, including those regarding mental and emotional health.

Click below for an automatic Google search that will show the many news and blog posts about D-MER.