Dysphoric Milk Ejection Reflex (DMER)

Dysphoric Milk Ejection Reflex (DMER) is when a lactating person feels very strong negative emotions or physical sensations while breastfeeding. These feelings occur during the milk letdown (“milk ejection reflex”), when the milk starts flowing, and typically last only for a few moments. Despite its transient nature, it can be very distressing and concerning.

DMER – What is It?

DMER is the experience of short-lived but very strong negative emotions during the early moments of breastfeeding or pumping, when milk begins to flow (commonly known as the milk “letdown”). The feelings vary from person to person, but include:

• Sadness, emptiness, or a “hollow” feeling
• Anxiety, nervousness, panic, or dread
• Irritability, frustration, or feeling overwhelmed
• Tension or restlessness
• Nausea or a sinking feeling in the stomach

For most, these feelings start within seconds of the letdown and can last anywhere from a few seconds to a few minutes. The symptoms typically resolve but return at the next nursing or pumping session. This experience is different from depression or anxiety, which persist throughout the day.

DMER can be very confusing and distressing for people who desire breastfeeding. This makes it especially important for people to seek medical evaluation if they are experiencing these symptoms, so they can be correctly diagnosed and receive the support they need. Simply knowing that DMER exists can be validating for patients who are suffering from it. It is estimated that as many as 27% of lactating people experience DMER at some point.

What Causes DMER?

We do not fully understand the underlying cause of DMER, but it appears to be related to the transient increase in the hormone oxytocin that occurs at the time of letdown. Research is ongoing to try to more clearly understand the underlying mechanism for DMER, which will help us find the best treatments. People with underlying depression and/or anxiety are more likely to experience DMER, and mental health treatment for these individuals can help improve DMER symptoms.

What Can We Do for DMER?

Thankfully, DMER tends to lessen over the course of breastfeeding.

Beyond that, there are some behavioral tricks that can help make DMER more manageable.

• Diagnosis and support groups. Knowing what is going on and that there is nothing wrong with you can be very helpful by itself and can help you feel less alone in the experience.
• Meditation or other mindfulness activities. Some people find that mindfulness in general can help them tolerate the symptoms better when they do happen.
• Distraction. Many find that reading a good book, watching a funny TV show, thinking about funny jokes, or doing another quiet and enjoyable activity when they can anticipate the symptoms can help them get through the low moments more easily.
• Cognitive Behavioral Therapy (CBT): CBT is a proven therapy technique that helps us manage negative thoughts and emotions. This can be a powerful form of therapy. See IABLE’s handout on Mental Health Resources in the United States for ideas on where to find this type of support.
• General self-care: Making sure you are getting enough sleep, eating well, and taking care of yourself and your general mental and physical health can improve DMER.
• Try a different method of expressing milk: Some people find that their symptoms are not as severe when they pump as when they nurse. Some find exactly the opposite. Experimenting with this and potentially doing a combination of the two may help symptoms.

Beyond these behavioral techniques, there are some medications and other prescription treatments that can help lessen DMER symptoms. If you are experiencing symptoms of DMER and do not feel that things are improving after trying some of the above options, reach out to a breastfeeding specialist or perinatal mental health professional for help.

The Outlook for DMER

As mentioned previously, DMER tends to improve with time. 30% of people who experience DMER do find that the symptoms lessen with time, and for some it goes away completely. But people who experience DMER are at risk of experiencing it again with subsequent lactation journeys. Hopefully as the body of research on DMER grows, we will understand it more clearly and will develop more ways to help people who experience it.