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Dysphoric milk ejection: the real reason you might feel sad when breastfeeding

As a health visitor, you get used to friends with babies asking questions about sleep, feeding and dirty nappies. Usually, these are straightforward, or you can at least direct people to the right help. But every once in a while, you get asked something unusual.

My friend (let’s call her Lisa) had a baby girl last spring. As with lots of women, Lisa planned to breastfeed her baby. While breastfeeding causes anxiety for some women, Lisa wasn’t especially worried about giving it a go.

She initially told me that the breastfeeding was going well; the baby was latching on, and there were no problems. But when we recently met for a coffee, I heard a different story.

From day one, and just before every feed at the start of the let-down reflex (the reflex that makes the milk in the breasts available to the baby), Lisa experienced a sinking feeling in the pit of her stomach. A hollow, churning sensation, similar to homesickness, but unrelated to anything she could think of. The sensation would last a few minutes, then disappear. Disappear, that is, until the next feed.

At first, she put it down to a difficult birth, sleep deprivation and perhaps the baby blues. But the feeling was so odd, so out of sync with how she generally felt, that she told no one. She was worried people would think she had postnatal depression, and she wondered if indeed she did have postnatal depression. She kept it to herself and started to dread each feed.

Weeks went by. She continued to breastfeed and express milk while the disconcerting feeling also persisted. One night, after a particularly intense experience, Lisa looked online and found that other women also experience this feeling. At last, she wasn’t alone, and the feeling had a name: dysphoric milk ejection reflex or DMER.

Poorly understood

The term DMER was first coined in 2007 by Alia Heise, a lactation consultant who experienced the condition while breastfeeding her third child. Dysphoria is a state of unease, and milk ejection refers to the hormonal reflex by which breast milk is expressed from the mammary gland.

Little is known about DMER, but Heise and other lactation experts believe it is a physical rather than a psychological condition. When women breastfeed, dopamine (a hormone associated with reward) levels decrease for prolactin (milk producing hormone) levels to rise. Heise suggests that, for some women, dopamine drops excessively, and the resulting deficit causes a range of symptoms, including anxiety, anger and self-loathing.

Some studies have shown that low dopamine levels can cause low mood and other negative emotional responses, suggesting this may be the cause.

DMER is a spectrum. Some women may experience rage while others become anxious or despondent. Experiences of DMER also appear to differ both in their severity and duration. For some, DMER is mild and resolves in a few weeks. For others, symptoms can last for more than a year.

Although there was a documented case study of DMER in 2010, and a recently published case series (a descriptive study of a group of patients with a particular condition), no research on the mechanism of the condition has been undertaken – as a result, it is poorly understood.

Alia Heise discusses DMER.

Supporting women

DMER is not the same as “nursing aversion” (a feeling of irritability often accompanied by itchy skin while the infant is latched on to the breast), postnatal depression or anxiety, though these conditions may co-exist. Because DMER is not well known among healthcare professionals, there is a danger that some women may be misdiagnosed with mental health problems.

In some cases, the intensity of DMER can be severe enough to stop women from breastfeeding. Heise is keen to stress that just knowing about it and being able to talk to someone who understands, can make it easier to cope. There are a growing number of forums and websites where women can seek support and discuss their experiences, and the body of research on DMER, though small, is growing.

Lisa’s symptoms were mild enough that they resolved in a few months. She is still breastfeeding and is stoic about her experience. Would she breastfeed again? She answers unequivocally: “Absolutely.” Does she wish she had known about DMER before she got pregnant? “Well, of course.”

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