Dysphoric Milk Ejection Reflex
Why is this website here?
Dysphoric Milk Ejection Reflex (D-MER) may affect nearly ten percent of breastfeeding mothers, but it has never been studied. In 2011, Alia Heise and Diane Wiessinger, two since-retired lactation consultants, wrote a paper that named and described it, explored it through mothers’ experiences (including Alia’s), and performed some simple “kitchen table experiments” that led to a hypothesis. There have been other papers and hypotheses since then, but no research and no agreed-upon treatments.
Mark Shukhman, MD, has successfully treated women with a similar dysphoria, and agrees with our untested hypothesis. His website outlines our shared hypothesis and suggests possible approaches to treatment. He feels one treatment in particular shows real promise, but we’re all still learning.
Alia Heise and Diane Wiessinger
International Board Certified Lactation Consultants Retired
What is Dysphoric Mild Ejection Reflex? What isn't?
D-MER is a sudden flood of bad feelings that’s completely gone a minute or so after it starts. It happens only at the beginning of a breastfeeding or pumping session, just before your milk releases. It fades quickly, and doesn’t come back until the next session or next milk release. It’s not a stubborn cloud that hangs over you like postpartum depression.
Mothers describe D-MER as feelings of hopelessness, homesickness or wistfulness, of panic, paranoia, self-loathing, dread, anger or irritability, a sense of impending doom, or even thoughts of suicide. Within about a minute, these feelings vanish... only to come back at the beginning of the next nursing.
It can resemble postpartum depression, but women with D-MER have the dark feelings described above only at the beginning of a nursing.
What causes it?
The cause of D-MER is still unknown, but there are several hypotheses, involving the hormones of breastfeeding. Oxytocin, prolactin, and dopamine are the main players in milk production and release. Other pituitary, thyroid, and adrenal hormones and insulin are also involved. The Dopamine Hypothesis proposes that the unpleasant feelings of D-MER may be the result of a too-deep or too-rapid drop in dopamine at milk release.
The Dopamine Hypothesis
According to the Dopamine Hypothesis, D-MER is not a psychological response to breastfeeding, but a physiological response to milk release, also called let-down or milk ejection reflex.
A quick look at how breastfeeding works: There are two reasons why nursing mothers don’t just dribble milk from their breasts all day long:
· Milk can’t flow until it’s “allowed” to. That starts when oxytocin rises.
· More milk can’t be produced until it’s “allowed” to. That starts when dopamine falls.
Both things happen when your baby starts to nurse or you start to pump. Milk flows, and you start making more milk.
We know a lot about the oxytocin spike that lets milk flow. We know much less about dopamine. But research on sheep and rats points to an abrupt drop in dopamine around the time of milk release.*
* Knight PG, Howles CM, Cunningham FJ: Evidence that opioid peptides and dopamine participate in the suckling-induced release of prolactin in the ewe. Neuroendocrinol 1986, 44:29-35. Plotsky PM, Neill JD: The decrease in hypothalamic dopamine secretion induced by suckling: comparison of voltammetric and radioisotopic methods of measurement. Endocrinology 1982, 110(3):691-696.
Here’s what D-MER may look like:
Dopamine (DA in this graph) drops soon after the baby starts nursing, but with D-MER, it may drop too deep.
If the Dopamine Hypothesis is correct, then it may be possible to improve or eliminate D-MER by changing how significantly or how quickly it changes to facilitate the breastfeeding,
What can help D-MER?
The first thing to try is… cold water! Try drinking a half-cup of very cold water just before brining baby to breast or starting to pump. (Don’t sip slowly or use a straw.) Or suck on some ice chips. It’s not known why having a cold mouth can help, but many mothers with D-MER have found that it does. There are also online suggestions for other behavioral, environmental, and herbal approaches.
A medical approach that shows promise.
IF self-help suggestions aren’t enough, is the use of low-dose naltrexone, an approach used by Mark Shukhman, MD:
I was introduced to D-MER through the work of Alia Macrina Heise and Diane Wiessinger. But
The two dysphorias have striking similarities and, likely, similar mechanisms. Mothers’ experiences, published articles, and my own work with this similar type of dysphoria have given me confidence that the Dopamine Hypothesis is the most likely one, and I think that the same treatment approach [add link?] may work for both dysphorias. My treatment of postcoital dysphoria normally starts with a low dose of naltrexone. It may be the most promising first step for D-MER treatment too.
Low-Dose Naltrexone (LDN) - a promising treatment.
LDN improves your body's response to endorphins, the naturally-occurring opiates that your own body makes. We think that, with LDN's endorphin boost, your dopamine level will not drop as rapidly or as drastically. Moreover, it can address most of the other likely mechanisms involved in D-MER, including inflammatory response, regulation of thyroid hormone, adrenal hormones, and sex hormones.
The usual dose of naltrexone is considered safe for breastfeeding mothers and babies*. But the dose we use is only 1% to 10% of the usual dose!
If you’d like to consult with me about LDN or other D-MER treatments, feel free to schedule an appointment.
Hale TW. Hale's Medications & Mothers' Milk. TM 2021: A Manual of Lactational Pharmacology. Springer Publishing Company; 2020 Jul 14.
A few places to read further
§ D-MER.org - the most comprehensive collection of information
§ Dysphoric Milk Ejection Reflex (D-MER) Support Group on Facebook
§ Before the letdown: Dysphoric Milk Ejection Reflex and the breastfeeding mother https://tinyurl.com/47f6atcc.
§ Heise and Wiessinger’s 2011 D-MER article in the International Breastfeeding Journal
in the National Institute of Health website
There are answers to the D-MER puzzle. With your help, we may be able to find them for you, and for other mothers with this very disruptive piece of what should be a happy experience.
Low-Dose Naltrexone - a promising treatment.
We will offer you a few strategies for D-MER. Starting your treatment with a Low Dose of Naltrexone (LDN) is the most logical first step. LDN improves your body's response to endorphins, your naturally occurring opiates. We think that, with LDN's endorphin boost, your dopamine level will not drop as rapidly or as drastically. Moreover, It can address most of the mechanisms of D-MER, listed above, including inflammatory response, regulation of thyroid hormone, adrenal hormones, sex hormones, etc.
Even when it is used in its usual dose, naltrexone it considered safe in breastfeeding. You need to worry even less because the dose you will need is only 1% to 10% of the usual dose, which also was determined as safe.
Dysphoric Milk Ejection Reflex Help
Dr. Mark Shukhman's interest in D-MER was inspired by the works of Alia Macrina Heise and Diane Wiessinger, known in the field of lactation. For many years, they have been not only collecting data, but also gaining practical experience by being personally involved in helping D-MER sufferers. By the time Dr. Shukhman was introduced to D-MER, he had already developed a strategy for the treatment of a very similar intermittent dysphoria, postcoital dysphoria. The strategy is outlined in his chapter in "The LDN Book" and in his presentation at the LDN Research Trust 2016 Conference. The two dysphorias have striking similarities and, likely, similar mechanisms, which means that the same treatment approach may work.