| by Meghan Johnston, IBCLC
You sit down to nurse. You’re tired and looking forward to relaxing with your squishy new baby snuggled comfortably against your chest. You can’t wait to hear those reassuring sounds as he sucks, swallows, and breathes. You are ready. Ready to soak up the warm touch of your baby’s smooth skin, to stroke his back gently with one hand while supporting him with the other. You are ready to feel his tummy move in and out against yours as you enjoy the surge of oxytocin that will pulse through your veins telling your breasts it’s time to nurture your baby.
You have your water, your snack, and a good book. Baby latches on, you lean back, you relax, and take a deep breath as you comfortably melt into your couch, but as you exhale you feel like something is not right; maybe you feel homesick, or even helpless. You don’t know why or where this is coming from. These negative feelings, that can range from mild to severe, envelope you tightly as you struggle to understand how they could take up residence deep in the pit of your stomach while doing something you enjoy so much, breastfeeding.
A minute passes, baby begins gulping and you know your milk has let-down. Everything feels right again. In fact you may even forget about these feelings but next time you sit down to nurse or even if your milk let-down occurs without a nursling at the breast you are reminded, yet again, of these passing emotions that you struggle to understand. If this sounds familiar to you than you might have Dysphoric Milk Ejection Reflex or D-MER.
As a new mother with my first baby, a boy, the description above is my experience. After several months the symptoms improved greatly and pretty much disappeared as we nursed into toddlerhood. By the time I was pregnant with my second baby I had completely forgotten about these poorly understood emotions. Then she was born and the uncomfortable feelings were knocking at my breastfeeding door again.
Despite laying in my own bed or sitting on my own couch, every time I placed my brand new baby girl to the breast I felt homesick. It would fill me up with a mild sense of doom I just couldn’t shake. The feelings were brief so I accepted them and moved on. I began to expect these feelings just as much as I expected to see my baby start gulping. I knew they would visit just before I felt the familiar sensation of a milk release (note: not all women feel a milk ejection reflex) and expected them to leave within a minute or less.
These unexplained, poorly understood feelings were consistent and predictable. In fact, they were so predictable, even when baby wasn’t at the breast, I could tell if I was going to have a let-down because I would suddenly feel that all too frequent ickiness that started in the pit of my stomach and consumed my body like a virus.
Just as it slowly left me with my first baby, it faded with my second. It wasn’t until I stumbled upon an article about D-MER did I know that what I was experiencing had a name, or even that it existed beyond my own experience. It was my “a-ha moment!” A physiological reaction to a drop in dopamine!1
What is Dysphoric Milk Ejection Reflex?
According to D-MER.org “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.”2
Most women describe symptoms as lasting less than one minute. It is important to note this is not a psychological response but rather a physiological one.3 Many women with D-MER have been treated for post postpartum depression or other anxiety disorders without success.
Understanding the pathophysiology of D-MER is essential to helping women cope with, and treat, this condition. Since there has not been much research on D-MER it can only be theorized what is happening based on analyzing the symptoms of women who are experiencing this condition and comparing it to what we know about lactation and the milk ejection reflex.
The theory which fits all the pieces together best is that an abnormal drop in dopamine is occurring with the milk ejection reflex causing a brief dopamine deficit. We know dopamine regulates prolactin by blocking its release, therefore dopamine must drop in order for prolactin to rise, which is an essential part of lactation.
What we don’t know is when and for how long dopamine drops. It is theorized that this known, and normal, drop in dopamine occurs just before the milk ejection reflex. For women who are experiencing D-MER it is thought that dopamine drops to inappropriately low levels thus causing the known symptoms of said condition.4
Women with D-MER may experience widely varying degrees of dysphoria. Some women may simply feel a little homesick while others, in very rare instances, may experience suicidal thoughts or feelings of self harm.
One thing that remains consistent from one mother to the next is that the symptoms will come and go quickly and are always associated with the milk ejection reflex whether baby is at the breast, mom is pumping, or mom experiences a spontaneous milk ejection reflex without physical stimulation.5
According to the Australian Breastfeeding Association the most commonly reported symptoms are: hollow feelings in the stomach, anxiety, sadness, dread, introspectiveness, nervousness, anxiousness, emotional upset, angst, irritability, hopelessness, and something in the pit of the stomach.5
For most women symptoms will last for about three months while others might experience a longer duration. Less commonly for some women, symptoms of D-MER will last throughout the entire breastfeeding relationship.6
Not having D-MER with a first child is not a guarantee a breastfeeding mother won’t have it with a subsequent child; women with D-MER may experience it with every child or with just one.6
Women who are experiencing D-MER without knowing what it is may find the symptoms, even mild ones, quite difficult to manage. Not understanding what is happening can leave a mother disconcerted or feeling distressed and could lead to premature weaning.
Since D-MER is rare and not widely understood it can often go undiagnosed. For this reason education both to women and healthcare professionals is critical. Many women who have suffered from D-MER find education to be the only treatment necessary, especially in mild to moderate cases. Simply being able to label and understand what she is experiencing is often enough to manage the brief dysphoria a mother feels with each milk ejection reflex.
For severe cases, where the mother is at risk of weaning even after education has been offered, there are certain medications that can be effective at treating D-MER.7 Since anything that increases dopamine will help mitigate symptoms of D-MER lifestyle choices should not be ignored when considering a treatment plan; everything from diet to physical activity could theoretically help a mom with this condition.7
All women who suspect they are experiencing D-MER should seek help from a trusted medical professional who is familiar with this condition.