Understanding Dysphoric Milk Ejection Reflex

Defining & Describing D-MER

D-MER presents itself with slight variations depending on the mother experiencing it, but it has one common characteristic - a wave of negative or even devastating emotion just prior to letdown. This emotional response is the consistent key component in D-MER.  The breastfeeding mother experiences this surge of negative emotions about 30-90 seconds prior to her milk release when  breastfeeding, pumping or with spontaneous MER. By the time milk  actually releases and the baby starts gulping, the feelings have dissipated, only to return just prior to another MER. Although mothers with D-MER sometimes express the emotions a bit differently, there are many similarities with the terms and language that they use. Also, it is important to realize that because the intensity of the D-MER experience is variable, the emotional responses experienced with D-MER fall within a three-level spectrum: despondency, anxiety and agitation. The most commonly used words used are: a hollow feeling in the stomach, anxiety, sadness, dread, introspectiveness, nervousness, anxiousness, emotional upset, angst, irritability, hopelessness and general negative emotions.

How D-MER Presents

The negative emotions, or dysphoria, that a mother with D-MER experiences often manifest "in the mother's stomach" - a hollow feeling, a feeling like there is something in the pit of the stomach, or an emotional churning in the stomach. Mothers report varying types of emotions with D-MER ranging from sadness and dread to anxiety to anger, these emotions fall on the D-MER spectrum which has three different common experiences. 

The common thread between these three different experiences is the wave of negative emotions. the dysphoria, prior to letdown. This happens when nursing and most often with expressing and spontaneous letdowns as well. The dysphoria then lifts within another 30-90 seconds, and then usually repeats with each letdown.

A key piece of D-MER is that a mother with D-MER feels absolutely fine except just before her milk starts to flow. D-MER is a brief feeling, not more than 30 seconds to 2 minutes, only and always beginning before let-down. This is not postpartum depression and most of these mothers feel perfectly fine except for that pre-milk moment. A brief interval after the negative feelings appear, the milk begins to flow.

Milk Ejection Reflex Intensity and Duration

Some mothers have very mild D-MER, often describing it simply as a "sigh" or a "pang." However, on the other end of the scale of intensity, there are some mothers who feel extreme emotions resulting in suicidal ideation, thoughts of self-harm or feelings of anger. 

These feelings are usually brief and rarely do they act on them. These mothers need to be encouraged and supported and not treated as an abuse risk. They may also need to consider more serious treatment in order to more effectively manage their D-MER.  

It is important to note that a mother's D-MER will be harder to handle if she also has PPD or an anxiety disorder. Most mothers notice the onset of D-MER within the first couple weeks of breastfeeding and for some it will be gone by the time the baby is three months old. 

Other mothers find that D-MER gets less severe and slowly dissipates as the baby ages and then at some point realize they are no longer experiencing it. For others it remains until weaning, regardless of the baby's age.

Nursing with D-MER

Not every breastfeeding mother with a negative feeling when breastfeeding has D-MER and weaning is usually not necessary.

D-MER is not a breastfeeding problem that  mothers use an excuse to give up breastfeeding, or at least give up easily. Mothers who truly do have D-MER can use their new found diagnosis as encouragement so that they can continue breastfeeding. This is why d-mer.org is here and why the battle was fought to make it a recognized condition, so that mothers were empowered, so that they understood what was happening and so that they could go on. Mothers can diagnose themselves, of course, especially if they are not seeking treatment. But it needs to be done thoughtfully and carefully and not used as a reason to not choose breastfeeding.

Some mothers report having D-MER-type feelings with other medical causes. Though it is not a rule by any means it has been found that a few mothers explain having D-MER type feelings unrelated to lactation in the following situations: restless leg syndrome, premenstrual dysphoric disorder, prior to hot flashes during menopause, emotional reaction to nipple play in sexual situations, a dysphoric feeling in the stomach prior to experiencing a seizure and dysphoria after orgasm. These situation may all be dopamine mediated and it is possible that if a mother has a history of dysphoria in these situations she may be more predisposed to D-MER. 

Recognizing D-MER

The way a mother describes her D-MER helps determine the diagnosis of D-MER. Mothers with D-MER often use very similar language and words. Very rarely will be an utterance of "I don't like breastfeeding". In fact many mothers with D-MER like breastfeeding aside from their moments of dysphoria. When a mother begins to open up about the negative feelings she is having at the time of milk release she often uses many of the following words and phrases: hollow, intense, feels like, seconds, stomach, rush, overwhelming, minutes, fade away, feelings, before letdown, lose of appetite, wave, sudden, pit in stomach, negative. 

D-MER happens with milk letdowns. When and how often she experiences D-MER with letdowns helps determine D-MER. A mother with D-MER will experience dysphoria with at least the first milk ejection reflex of a feeding while the baby is at the breast. This is part of the criteria for diagnosis. She may also experience dysphoria with further MERs during the feeding (2-12 during a feeding is possible). Many mothers with D-MER have dysphoria with MER(s) during pumping and with spontaneous milk ejection but these points are not necessary criteria for a diagnosis. There have been a very small sample of mothers that have reported experiencing dysphoira just when they pump and not when they put the baby to the breast, we are still exploring the possibility of this being D-MER, it is not yet known. It is known that exclusive pumpers can have D-MER and many mothers report the dysphoira with pumping and with spontaneous letdowns to be worse than the dysphoira with MER that is felt when the baby is at the breast. It is felt at this time that this is possible because the bonding and oxytocin effect is greater when nursing at the breast than it is with spontaneous letdowns and with pumping. Meaning, higher oxytocin levels may help cancel out some of the dysphoric feelings.

Predisposition and Cause

A mother's medical or personal history does not dictate D-MER. Mothers do not get D-MER because they were sexually abused or because of a traumatic birthing experience. If a mother feels reminiscent of an earlier time in her life during D-MER it is not indicative of a psychological response to breastfeeding. When a mother experiences D-MER, the emotions she feels may cause her to remember those upsetting times in her life, but the experiences are not triggering the D-MER. The emotions she experiences with D-MER may be reminiscent of how she felt during those times, and therefore make her think back to them because the feeling is similar. This is likely because D-MER by itself  creates this dopamine drop in a mother's body, making her feel this way regardless of her past life experiences. If she happened  to have a life experience in the past that caused the same dopamine drop to occur, then she is likely to have a deja vu feeling with each D-MER as that dopamine drop repeats itself.

No likely predisposition to D-MER other than a history of D-MER  It is not yet known what causes one mother to have D-MER and not another. At this time is appears to be a breakdown in the way the hormone functions, since once a mother has D-MER, she will have it with any subsequent nurslings.  

It is known D-MER is dopamine mediated but it is unknown why some mothers have this particular problem and not others. It could be an environmental effect, a nutritional deficiency, a breakdown in normal hormonal activity as she ages. It could be she is more sensitive to a normal drop in dopamine, dopamine receptor mutation,  a predisposition to abnormal dopamine activity or some other unknown cause.