Impact of Dysphoric Milk Ejection Reflex on Mental Health

Abstract

Objective:

Postpartum mental health, significantly influences breastfeeding. Dysphoric milk ejection reflex (D-MER) is defined as negative emotional reaction to milk ejection, such as unpleasant feelings, anger-irritability or a strange feeling in the stomach. This study investigates the impacts of D-MER on mothers experiencing negative emotions during breastfeeding.

Method:

This cross-sectional, descriptive study was conducted between July 1 and September 30, 2023 among surveyed mothers with babies of ages 0–2 experiencing discomfort while breastfeeding. Mothers reached out through Instagram and Facebook and completed a semi-structured 45-question survey using a Google form.

Results:

Out of 141 mothers, 27.7% (n: 39) had D-MER findings. Common emotions included tension (48%), exhaustion (43%), intolerance (41%), hypersensitivity (35%), and restlessness (33%). Symptoms reported to begin within the first month of breastfeeding in 59% of D-MER cases. Nausea was reported in 30% of mothers. The most common conditions that increased the severity of D-MER symptoms were insomnia, stress and breast fullness. Sleeping or resting, being alone, doing something else, drinking cold water, listening to music and talking to mothers who had similar experiences helped the mothers relax. In cases with D-MER findings, about 17.9% considered stopping breastfeeding, with 7.7% stopping. The postpartum depression score was ≥13 in 59% of D-MER cases.

Conclusion:

D-MER, which can cause early cessation of breastfeeding, may also be associated with the mother’s mental health problems. Raising awareness about D-MER and equipping health professionals on this subject are important in the continuity of breastfeeding.

Introduction

Breastfeeding provides many benefits for mothers and babies in the short- and long-term health. The World Health Organization recommends exclusive breastfeeding for the first 6 months and continued breastfeeding for at least 2 years.¹ But only 44% of babies are fed exclusively with breast milk for the first 6 months.² According to 2018 Turkiye Demographic and Health Survey data, the rate of exclusive breastfeeding for the first 6 months in Turkiye was 41%.³ Reasons for early weaning include pain or discomfort while latching, belief of insufficient milk and not being able to receive professional support.⁴ Negative breastfeeding experiences may lead to early cessation of breastfeeding.

Dysphoric milk ejection reflex (D-MER) is characterized by abrupt, negative emotional feelings, anger-irritability and a strange feeling in the stomach that starts just before the milk is released; it lasts a few minutes, affecting lactating or pumping women; and the symptoms disappear completely when the milk is released or the baby starts swallowing.⁵ Many mothers described their feelings such as anxiety, sadness, irritability, agitation, oversensitivity and tearfulness. D-MER findings may also be accompanied by nausea, tremors, palpitations and hollow or churning sensations in the pit of the stomach.^6,7 In a case report, D-MER is described as a feeling in the stomach “like when you hear bad news,” lasting for only a few minutes.⁸ Unlike postpartum depression, symptoms disappear after the milk flow begins.

D-MER was first described by Alia Macrina Heise in 2007.⁹ There are still a limited number of studies on this subject and rarely recognized by medical personnel. The first descriptive study, other than case reports, was published in 2019 and the prevalence of D-MER in breastfeeding women was found to be 9.1%.¹⁰ Breastfeeding is a complex and dynamic biological and psychological process that affects multiple emotions.¹¹

An inappropriate and temporary decrease in dopamine levels may be responsible for the D-MER experience experienced by mothers.⁹ Oxytocin is released almost immediately in response to suckling, while dopamine drops rapidly, allowing prolactin to rise in order to cause milk production. The sudden drop in dopamine is thought to be the cause of unpleasant feelings, possibly associated with D-MER.¹² Studies have shown that abnormal dopamine levels can cause emotional distress such as dysphoria, negativity, low mood and malaise.¹³

Apart from the role of dopamine, increased nipple sensitivity during pregnancy, high energy expenditure during breastfeeding, inadequate nutrition and sleep disturbance alongside hormonal imbalances can also cause negative feelings in mothers while breastfeeding. In addition, factors such as dehydration, caffeine intake, and mental stress may also exacerbate D-MER symptoms.^7,8

In a study, 75% of breastfeeding women experienced more than one milk ejection reflex during each breastfeeding session, so breastfeeding can be challenging for mothers who experience intense feelings of dysphoria before milk ejection.¹

While D-MER symptoms may decrease within 3 months, cases that continue experiencing these symptoms for the whole duration of breastfeeding have also been reported.¹⁴ It has been reported that it is more difficult to cope with the symptoms if postpartum depression accompanies D-MER or if the mother has a known anxiety disorder.⁹ The aim of our study is to investigate the presence of D-MER in mothers who experience unpleasant emotions during breastfeeding or pumping, the accompanying conditions, treatment methods and the effects of D-MER on the mother’s mental health.

Materials and Methods

This cross-sectional, descriptive study was conducted between July 1 and September 30, 2023, among mothers who had babies of ages 0–2 and “experienced unpleasant emotions while breastfeeding”. Mothers reached out via Instagram and Facebook were invited to a semi-structured survey of 45 questions created with an open-access Google Form. The questions in the survey were developed by the researcher within the framework of the information available in the literature.

The study was approved by Istanbul Medipol University Non-invasive Clinical Research Ethics Committee with document number E-10840098-772.02-2980.

First section of the survey, after obtaining consent, consisted of 22 questions about demographic and obstetrical information (age, employment status, education, occupation, partner’s education, family type, presence of mental health problems before pregnancy, previous diseases, pregnancy history, puerperal blues and postpartum depression, general stress level) and the emotions felt before the milk ejection and the presence of D-MER. Participants who answered the question “Do you experience negative emotions that you cannot control, such as depression, anxiety or anger, before breastfeeding/just before you start breastfeeding?” with a “Yes” or “Sometimes” were directed to a section consisting of 13 detailed questions about D-MER experiences. The survey ends with the 10 questions of Edinburgh Postnatal Depression Scale (EPDS).¹⁵ EPDS scores ≥13 are regarded as high likelihood of postnatal depression.¹⁶

Statistical analyses

Mean, standard deviation, median lowest and highest, frequency and ratio values were used in the descriptive statistics of the data. The distribution of variables was measured with the Kolmogorov–Smirnov test. Chi-square test was used in the analysis of qualitative independent data. Fischer’s test was used when chi-square test conditions were not met. SPSS 28.0 was used in the analyses.

Results

Of the total 141 participants, 72.3% were between the ages of 20 and 34 years and 59.6% were university graduates. The rate of exclusive breastfeeding was determined as 44.7%. While 73% of mothers stated that they generally enjoyed breastfeeding, 21.3% of mothers had an irresistible desire to separate the baby from the breast during breastfeeding. Total 66.7% of mothers have postpartum blues. The rate of mothers who experienced postpartum depression in their previous pregnancies was found to be 2.8% (Table 1).

Table 1.

Demographic Features

	n: 141	%
Age
20–34	102	72.3
>35	39	27.7
Occupation
Working	47	33.3
Maternity leave	59	41.8
Housewife	35	24.8
Education
Elementary	1	0.7
High school	9	6.4
College	84	59.6
Master’s/PhD	47	33.3
Partner education
Elementary	4	2.8
High School	17	12.1
College	86	61.0
Master’s/PhD	34	24.1
Family type
Nuclear Family	135	95.7
Extended Family	6	4.3
Psychiatric diagnosis prior to pregnancy
No	111	78.7
Yes	30	21.3
Past illnesses
No	103	73.0
Yes	38	27.0
Number of pregnancies
I	99	70.2
II	32	22.7
III	9	6.4
IV	1	0.7
Medication use during pregnancy
No	6	4.3
Yes	135	95.7
Gestational age at birth
<30 weeks	3	2.1
30–33 weeks, 6 days	1	0.7
34–36 weeks, 6 days	16	11.3
≥37 weeks	121	85.8
Feeding type
Exclusively breastfed	63	44.7
Complemantary feeding with breast milk/formula	40	28.4
Mix feeding	38	26.9

	n: 141	%
Postpartum blues
No	47	33.3
Yes	94	66.7
Postpartum depression
No	137	97.2
Yes	4	2.8
General stress level
I	10	7.1
II	32	22.7
III	48	34.0
IV	41	29.1
V	10	7.1
Enjoying breastfeeding
No	6	4.3
Yes	103	73.0
Sometimes	32	22.7
Desire to interrupt breastfeeding
No	111	78.7
Yes	30	21.3
Tandem breastfeeding
No	137	97.2
Yes	4	2.8
Presence of depression, anxiety or anger before lactation/just before breastfeeding
No	102	72.3
Yes	11	7.8
Sometimes	28	19.9
Nausea or a strange feeling in the stomach
No	105	74.5
Yes	18	12.8
Sometimes	18	12.8

Among the 141 mothers who reported experiencing unpleasant emotions while breastfeeding, 27.7% (n: 39) had D-MER findings. In 89.7% of the cases, D-MER symptoms appeared in the first pregnancy. Among the D-MER cases, the most common emotions experienced before milk ejection were tension for 48% (n: 19), burnout for 43% (n: 17), intolerance for 41% (n: 16), hypersensitivity for 35% (n: 14) and restlessness for 33.3% (n: 13) of the mothers (Table 2).

Table 2.

D-MER Symptoms

	n	%
Tension	19	48
Burnout	17	43
Intolerance	16	41
Hypersensitivity	14	35
Restlessness	13	33.3
Strange feeling in stomach	12	30
Guilt	10	25
Anxiety	10	25
Confusion	9	23
Feeling of worthlessness	8	20
Lack of focus	7	17.9
Depression	6	15
Irritability	6	15
Disappointment	5	12
Fidgety	4	10
Sadness	4	10
Panic	3	7
Homesickness	3	7
Agitation	2	5
Paranoid thoughts	2	5
Anger	1	2

D-MER, dysphoric milk ejection reflex.

Findings regarding D-MER symptoms are shown in (Table 3). Among D-MER cases, the rate of feeling symptoms when they start breastfeeding was 46% (n: 18), while the rate of feeling symptoms when they start pumping and during pumping was 25% (n: 10) and the rate of feeling symptoms with spontaneous milk flow between breastfeeding sessions was 28% (n: 11). In 69.2% (n: 27) of D-MER cases, symptoms appeared suddenly and without a triggering factor.

In 43.6% (n: 17) of the cases, the symptoms disappeared within 1 minute after starting breastfeeding and in 43.6% (n: 17), the symptoms lasted between 1 and 5 minutes. It was found that in 38.5% of the cases, symptoms recurred before each milk ejection during a breastfeeding session.

Of the 24 participants who pumped milk, seven reported experiencing symptoms similar to those during breastfeeding, and seven reported worse symptoms.

Symptoms appeared in the first month of breastfeeding in 59% (n: 23) of D-MER cases and continued throughout the breastfeeding period in 33.3% of cases. In only 17.9% of the cases it was found that the symptoms improved within the first month.

Most of the mothers who experienced D-MER (53.8%; n: 21) felt pressured by feelings of guilt and shame owing to the emotions they experienced (Table 3).

The activities that most positively affected D-MER symptoms were sleeping or resting, being alone, doing something else, drinking cold water and listening to music (Table 4).

Table 3.

Characteristics of D-MER Cases

	n	%
Onset of symptoms
<1 month	23	59.0
1st–3rd months	8	20.5
3rd–6th months	5	12.8
>6 months	3	7.7
Duration of symptoms (min)
≤1	17	43.6
1–5	17	43.6
>5	5	12.8
Symptoms recurring during the same breastfeeding session
Yes	15	38.5
No	24	61.5
Symptoms with pumping compared with breastfeeding
Same with breastfeeding	7	17.9
Better	3	7.7
Worse	7	17.9
No symptoms during pumping	7	17.9
Doesn’t do pumping	15	38.5
Duration of symptoms (month)
<1	7	17.9
1–3	10	25.6
3–6	5	12.8
>6	4	10.3
Feelings of guilt/shame
Yes	21	53.8
No	18	46.2
Similar previous experience
Yes	4	10.3
No	18	46.2
Don’t know	17	43.6
Symptom severity compared with previous experience
Same	3	7.7
Worse	1	2.6
Less severe	1	2.6
Didn’t experience it before	3	7.7
First pregnancy	31	79.5
Desire to stop breastfeeding
Would like to stop	7	17.9
Stopped	3	7.7
Don’t want to stop	23	59.0
No answer	6	15.4

D-MER, dysphoric milk ejection reflex.

Table 4.

Activities That Relieve D-MER Symptoms

	n	%
Sleeping/resting	18	46.2
Being alone	17	43.6
Distracting themselves	13	33.3
Drinking cold water	10	25.6
Listening to music	9	23.
Talking with mothers experiencing similar symptoms	8	20.5
Eating	8	20.5
Therapy	4	10.3
Pumping instead of breastfeeding	3	7.7
Exercising	2	5.1
Vitamin supplementations	2	5.1
None of the listed	1	2.6

D-MER, dysphoric milk ejection reflex.

Table 5.

Situations Increasing the Frequency of D-MER Symptoms

	n	%
Insomnia	30	76.9
Stress	27	69.2
Breast fullness	11	28.2
Orgasm	5	12.8
None of the listed	3	7.7
Dietary changes	1	2.6
Caffeine consumption	1	2.6
Inability to socialize	1	2.6

D-MER, dysphoric milk ejection reflex.

Table 6.

Comparison of Characteristics of Mothers with and without D-MER

	D-MER (−)		D-MER (+)		p
	n	%	n	%	p
Age (year)
20–34	74	72.5	28	71.8	0.929	χ²
>35	28	27.5	11	28.2	0.929	χ²
Occupation
Working	36	35.3	11	28.2	0.700	χ²
Maternity leave	42	41.2	17	43.6
Housewife	24	23.5	11	28.2
Education
Elementary	1	1.0	0	0.0	0.195	χ²
High school	8	7.8	1	2.6
College	58	56.9	26	66.7
Master’s/PhD	35	34.3	12	30.8
Family type
Nuclear family	98	96.1	37	94.9	0.668	χ²
Extended family	4	3.9	2	5.1	0.668	χ²
Psychiatric diagnosis prior to pregnancy
No	84	82.4	27	69.2	0.089	χ²
Yes	18	17.6	12	30.8	0.089	χ²
Medical history
No	74	72.5	29	74.4	0.828	χ²
Yes	28	27.5	10	25.6	0.828	χ²
Number of pregnancies
I	64	62.7	35	89.7	0.002^∗	χ²
II	29	28.4	3	7.7
III	8	7.8	1	2.6
IV	1	1.0	0	0.0
Medication use during pregnancy
No	4	3.9	2	5.1	0.668	χ²
Yes	98	96.1	37	94.9	0.668	χ²
Gestational age at birth (week)
<30	2	2.0	1	2.6	0.183	χ²
30–33	0	0.0	1	2.6
34–36	10	9.8	6	15.4
≥37 weeks	90	88.2	31	79.5
Feeding type
Exclusively BF	44	43.1	19	48.7
BF/Formula + complementary feeding	30	29.4	10	25.6
Mix feeding	28	27.4	10	25.7	0.849	χ²
Postpartum blues
No	39	38.2	8	20.5	0.046^∗	χ²
Yes	63	61.8	31	79.5	0.046^∗	χ²
Postpartum depression
No	100	98.0	37	94.9	0.306	χ²
Present during last pregnancy	2	2.0	2	5.1	0.306	χ²
General level of stress
I	10	9.8	0	0.0	0.002 ^∗	χ²
II	29	28.4	3	7.7
III	34	33.3	14	35.9
IV	25	24.5	16	41.0
V	4	3.9	6	15.4

*p < 0.05 accepted as significant.

D-MER, dysphoric milk ejection reflex; BF, Breastfeeding.

The conditions that increased D-MER symptoms the most were insomnia, stress, and engorgement (Table 5).

It was found that 17.9% of D-MER cases thought about stopping breastfeeding and 7.7% stopped breastfeeding for this reason.

The average EPDS score was 15.1 ± 5.6 (min: 3.0; max: 26.0) and in 59% of D-MER cases, the score was ≥13.

Between two groups, demographic data (patients’ age, employment status, education, family type), mental health problems, medical problems, drug use during pregnancy, gestation and feeding type had no significant (p > 0.05) correlation. The rate of first pregnancy in D-MER cases was significantly (p < 0.05) higher than that in the non D-MER group. When the general stress level score of the participants was between 1 and 5, the number of participants with stress level score of 4 was significantly higher in D-MER cases (p < 0.05) (Table 6). The rate of postpartum blues was found to be significantly (p < 0.05) higher in D-MER cases than in the non D-MER group.

The rate of nausea or a strange feeling in the stomach that could not be described before breastfeeding or just before milk release was found to be significantly higher (p < 0.05) in the D-MER group than in the non D-MER group.

The rate of negative sensations such as need to interrupt breastfeeding was found to be significantly (p < 0.05) higher in the D-MER group than in the non-D-MER group. The D-MER group had significantly lower (p < 0.05) feelings of enjoying breastfeeding than the non D-MER group.

Discussion

D-MER was first described in 2007 by Alia Macrina Heise, who created the website D-MER.org in 2008. The first official documentation of D-MER was a case report published in 2010.⁹ Although information about this unpleasant experience is increasing, many health care professionals still do not have sufficient information about D-MER. In our study, the frequency of D-MER was determined as 27.7% and the most common findings were tension, burnout, and intolerance. Symptoms appeared in the first month in 59% of the cases and were found to decrease with sleep or rest, being alone and doing with something else. EPDS score was >13 in 59% of the cases and breastfeeding was stopped early owing to D-MER in 7.7% of all cases.

D-MER is a relatively new and under-researched area of breastfeeding. The first study on this subject was published by Ureno et al. in 2019, and it was reported that the incidence in breastfeeding women was 9.1%.¹⁰

In a recent study, the median age was found to be 36.¹⁷ In a study where 15 D-MER cases were evaluated, it was found that the majority of the cases were between the ages of 20 and 34, and these were college graduates.¹⁰ In our study, 71.8% of the mothers were between the ages of 20 and 35, and 97.5% were university graduates.

Similar to literature, in our study it was determined that 89.7% of D-MER cases had their first pregnancy and almost half of the babies were exclusively breastfed.¹⁷ Heise et al. claims D-MER to be independent of a woman’s birth or living experiences and can occur abruptly and intensely after several normal breastfeeding sessions.⁹

The most prominent symptoms of D-MER are feeling anxious, restless, and tense. The most commonly used words are a hollow feeling in the stomach, anxiety, sadness, dread, introspectiveness, nervousness, anxiousness, emotional upset, angst, irritability, hopelessness, and general negative emotions.¹⁸ In one descriptive study, respondents reported feeling anxious (83.8%), sad (63.6%), panicky (54.5%), irritable (53.5%), oversensitive (52.5%), agitated (50.5%), and tearful (50.5%).¹⁰ In our study, it was determined that the emotions felt immediately before milk release in D-MER cases were tension, exhaustion, intolerance, hypersensitivity and restlessness.

Factors that exacerbate symptoms in D-MER are both physical and psychological. Fatigue, insomnia, stress, breast fullness, and caffeine aggravate D-MER symptoms,¹⁰ while resting, hydration, and exercise were beneficial for coping with symptoms.⁹ In our study, it was found that the most common situations that increased the severity of D-MER symptoms were insomnia, stress, and breast fullness.

D-MER symptoms vary in intensity, duration, and frequency. In general, the more intense the experience, the longer it is likely to last.⁹ In our study, it was found that the symptoms of D-MER cases appeared in the first month of breastfeeding at a rate of 59%.

In the study conducted by Heise et al., nearly half of the mothers stated that their symptoms did not disappear completely until they weaned and some of them stated that the symptoms disappeared owing to changes in feeding frequency as the child grew older.⁹ Ureño et al. reported that D-MER symptoms lasted between 6 months and 1 year in 48.4%, while it lasted for more than 1 year in 29% of the mothers.¹⁰ In our study, D-MER symptoms were continued throughout breastfeeding in one-third of the cases.

In D-MER, negative emotions are triggered not only from nipple stimulation, but also with breastfeeding, mechanical or manual milk expressing, thinking or milk secretion owing to the fullness of the breast, which all cause milk ejection.⁹ In our study, 17.9% stated that their D-MER symptoms were worse with pumping, and 17.9% stated that their symptoms did not change when they breastfeed or pumping.

There are no approved medical products for the treatment of D-MER. It has been reported that foods and medications that alter dopamine levels, such as bupropion, can be effective in relieving or even eliminating dysphoria. The effectiveness of these preparations has not been proven, and further studies are needed on the safety of the drug and its effect on the child.⁸ One study reported that the use of Rhodiola rosea and vitamin B complexes as herbal medicine is effective, but there are no studies on its safety for babies.^8,19

D-MER symptoms can be alleviated through self-regulation and lifestyle modifications.¹⁹ Mothers should moderately increase their water intake, exercise regularly, get enough sleep and reduce caffeine consumption.^9,10,12 Reading, watching TV, listening to music, aromatherapy, conversation and other recreational activities during breastfeeding can distract mothers from symptoms. In our study; mothers benefited from sleep or rest, being alone, doing something else, and drinking cold water.

Negative consequences of D-MER include undesirable early weaning, continued breastfeeding under stress, negative effects on mother–infant attachment, and mothers feeling guilty about the emotions they experience.¹ In our study, it was found that 17.9% of D-MER cases thought about stopping breastfeeding and 7.7% of them stopped breastfeeding for this reason.

There’s not enough information to observe whether all cases of D-MER would resolve before natural weaning, for very few women with severe symptoms seem able to continue breastfeeding long enough to weaning.⁹ Liu et al. reported one patient who chose early weaning after struggling with D-MER symptoms for six months and her symptoms disappearing after weaning; and another case continuing to breastfeed her daughter until she was 18 months old with the help of professional counseling and then her symptoms disappeared.¹² D-MER symptoms continued for > 6 months in four of our cases.

D-MER is not a psychological disorder, but a physiological problem caused by hormones and that it is different from postpartum depression.¹² In one study, 45% of women with D-MER scored ≥13 on the EPDS.²⁰ In our study, the score was ≥13 in 59% of D-MER cases. Therefore, it would be useful to evaluate mothers with a history of anxiety or depression in terms of D-MER.

Several researchers suggested that D-MER triggers the fight-or-flight response, thus causing breastfeeding mothers to feel unsafe, leading to an increased stress response.^1,7 In our study, the general stress levels of D-MER cases were found to be significantly higher.

Informing mothers about D-MER, connecting them with mothers who had similar experiences relieves them about the extraordinary reactions they feel about breastfeeding. Raising awareness about D-MER and forming support groups would decrease the potential harm it may cause.²¹ In our study, meeting with mothers who had similar complaints was a relief for the mothers.

One of the strengths of our study is the high number of participants. Another strength is the evaluation of the participants in their depression and stress levels alongside the D-MER findings.

A limiting factor in our study is almost all of the participating mothers were college graduates. There is need for wide studies including different sociodemographic features. In addition, the survey used in this study was prepared by the researcher, and its validity and reliability studies have not been conducted yet.

Conclusion

D-MER is one of the factors associated with early cessation of breastfeeding. Mothers’ difficulty in expressing the negative emotions they experience, their misconception that this may be a psychological disorder and sometimes their embarrassment because they do not have ‘the positive emotions they should have' during breastfeeding all affect a mother’s mental health. Increasing the awareness of both mothers and health care professionals about D-MER is critical in maintaining breastfeeding.

Footnotes

Authors’ Contributions

A.K. designed the study, interpreted the results, and wrote the preliminary versions of the article; Ö.Ö., Ö.B., and D.D.B. interpreted the results and critically appraised the article for intellectual content; F.K. and M.B. analyzed the data, interpreted the results, and wrote the preliminary versions of the article; N.K. designed the study, interpreted the results, critically appraised the article for intellectual content, and supervised the study.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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