One of the problems that is still relatively unexplored and unexplained is dysphoria during milk ejection reflex (D-MER; Dysphoric Milk Ejection Reflex), which occurs at the onset of the milk release reflex from the milk ducts.
This phenomenon involves a negative experience of breastfeeding. Given that it occurs at the moment milk release begins, for which oxytocin is responsible, and considering the findings of the study conducted by Fernandez et al. (2012), it would be necessary to consider a connection between the use of synthetic oxytocin during childbirth and the onset of this phenomenon.
To begin, let’s quote an Australian mother who described her experience of dysphoria during milk ejection reflex with a metaphor:
»If you have read Harry Potter they talk about the creatures that suck the soul out of you and when they are around it makes you cold and you start to focus on negative things and fall into this abyss of negative thoughts – that is how D-MER was for me at times. « (Australian breastfeeding association, 2012). Which translates to: “If you have read Harry Potter, you know that the story also features creatures that suck your soul. Their presence makes you feel cold, makes you start focusing on negative things, and plunges you into an abyss of negative feelings – that’s how I felt when dealing with D-MER.”
Both Heise and Wiessinger (2011) and Lawrence and Lawrence (2011a) emphasize the importance of informing professionals about the existence of this phenomenon and warn that this area still needs further research.
GENERAL INFORMATION ABOUT D-MER
D-MER is therefore a phenomenon of negative emotions or feelings 30–90 seconds before milk release, whether during breastfeeding, pumping, or merely a spontaneous milk ejection reflex. From the moment milk actually begins to release until the baby starts sucking, this phenomenon may already pass. This wave of negativity thus lasts a few minutes and then completely subsides. It is important to emphasize that the entire process repeats just before the next milk ejection reflex. How strongly a mother feels and experiences this problem depends on each individual. However, it has one common characteristic in all: a wave of negative feelings, which can even be “destructive” for some individuals – suicidal thoughts. This emotional response is the key component of D-MER. Different intensities of experience divide emotional responses into three levels: despondency/dejection, anxiety, and agitation. Most often, women describe this phenomenon with the following words: a feeling of emptiness in the stomach, anxiety, worry, sadness, nervousness, irritability, forgetfulness, dejection, introspection, apathy, and general negative feelings (Heise, 2011).
Heise and Wiessinger (2011) state that D-MER usually occurs with all children or only with younger ones. They suggest (Heise and Wiessinger, 2011) that the onset of D-MER might increase with the mother’s age.
PHYSIOLOGY OF D-MER
It is a physiological problem, not a psychological one, with dopamine playing an important role (Heise, 2011). This was also confirmed by an online questionnaire compiled by Heise and Wiessinger (2011). They found that none of the participating mothers believed in a psychological origin. They state that many had previously considered the phenomenon to be conditioned by past or present events.
As previously mentioned, dopamine inhibits prolactin secretion (Riordan, 2010). For milk synthesis, an elevated prolactin level is required, meaning that the concentration of dopamine in the blood must decrease. At the same time, the milk ejection reflex must occur, which is triggered by oxytocin. The milk ejection reflex can be triggered by the newborn sucking the nipple, excessive breast fullness, thinking about the baby, or something else, and it is at this moment that dopamine drops, followed by a slow increase in prolactin concentration. In mothers who experience D-MER, the drop in dopamine concentration in the central nervous system occurs too quickly or too extensively, or can even fall to a very low concentration. With the onset of this sudden drop in dopamine in such mothers, the dopamine receptors located in the brain’s pleasure center are deprived, leading to a rush of negative feelings. Tingling and nausea, which can occur with the milk ejection reflex, are something entirely different from D-MER, although they can accompany it. Likewise, D-MER is not postpartum depression, although it can occur simultaneously. Mothers who struggle with this are, generally speaking, happy and content between D-MER episodes (Heise, 2011).
Mothers do not have this problem due to a bad birth experience or a potentially negative sexual history (rape). It is true that these feelings can remind them of stressful situations they have experienced. However, the experiences themselves are not triggers for D-MER. A sudden drop in dopamine forces some mothers to relive past events. This happens because dopamine drops to the same concentration as it did during that event (Heise, 2011).
INTENSITY AND DURATION OF D-MER
Like all phenomena, D-MER can manifest with varying intensity. Some mothers have a mild form of D-MER, which they describe merely as twinges, but there are also those who experience the highest level of intensity. This extremity is primarily manifested in suicidal thoughts, feelings of anger, or thoughts of self-harm. Such feelings are most often short-lived and rarely acted upon. Such a mother does not need to be “stigmatized” as a threat, but rather needs encouragement and support. She also needs a more serious form of treatment, meaning medication, to be able to manage her D-MER. For a mother suffering from postpartum depression or any other mental disorder, treatment will be more difficult to control. Some mothers report that D-MER appeared in the first weeks of breastfeeding and subsided after three months of breastfeeding. For some, it gradually becomes milder and slowly fades away. Of course, not all mothers are so lucky and deal with it throughout the entire breastfeeding period (Heise, 2011).
Regardless of its intensity, D-MER is not a valid reason to stop breastfeeding. No breastfeeding mother should stop breastfeeding her child as long as possible and as long as the child desires it. The fact is that D-MER, by causing negative feelings and discomfort, leads mothers to this decision. Because of this, many mothers decide to stop breastfeeding (too) early. It is important to know that premature weaning can also negatively or even more severely affect the mother. It can cause feelings of guilt, which can lead to new problems. She may start blaming herself for being a bad mother, for not being able to meet the child’s basic needs, and so on. Informing breastfeeding mothers that what they feel during breastfeeding is a medical or hormonal problem would help many to accept and process the negative feelings they are exposed to. Many would also realize that premature weaning is meaningless. Those who would still consider it should be encouraged to seek treatment (Heise, 2011).
TREATMENT
For mothers with mild or moderate intensity D-MER, education plays an important role in treatment. The fact is that many find it easier to come to terms with D-MER and its symptoms once they learn that it is not a psychological problem. Such mothers should be encouraged to record their D-MER episodes, observe them carefully, or even write them down as an aid in identifying activities or events that worsen them (coffee, stress, dehydration) and those that help alleviate them (increased hydration, rest, physical activity). Those with a more serious or more intense form require medical treatment with substances that cause an increase in dopamine concentration. Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant most commonly prescribed and are not effective in treating D-MER (Heise, 2011). Lawrence and Lawrence (2011a) also point out that antidepressants do not help and emphasize the importance of using appropriate herbs.
Heise and Wiessinger (2011) stated in their report that Heise found data indicating that common rhodiola, or Rhodiola rosea in Latin, inhibits monoamine oxidase, which causes a drop in dopamine and thus contributes to a slight increase in concentration. Otherwise, Rhodiola rosea falls into safety category B, meaning it is not exactly suitable for self-treatment. In some cases, or improper use, it can cause negative effects. For Heise, the use of common rhodiola capsules alleviated D-MER symptoms. When she forgot to take the medicine, the symptoms intensified again. As Khanum et al. (2005) state, Rhodiola rosea stimulates the effect of neurotransmitters such as serotonin, epinephrine, dopamine, and nicotinic receptors in the central nervous system. It also improves the effect of these neurotransmitters on the brain by increasing the permeability of the blood-brain barrier. Changes in the level of monoamine neurotransmitters in the nerves affect the regulation of will, anxiety, and emotions in the amygdala, hippocampus, and hypothalamus, which consequently affects an individual’s feelings (Khanum et al., 2005).
Although D-MER is not a publicly known phenomenon, during the period of preparing and searching for literature for my diploma thesis, individuals began to contact me after I posted that I was looking for candidates to participate in the thesis. They recognized themselves in the description of D-MER itself. This means that it also exists in Slovenia, but women do not talk about it for various reasons. Most have no idea what is actually happening to them. I hope that the testimony of the lady who also agreed to participate will encourage other mothers who are experiencing or have experienced a similar situation to speak up. With their help, we could gain new insights into D-MER and thus contribute to better care for individuals with this problem.
It would be interesting to study more precisely what happens to hormone concentrations during the active phase of D-MER itself and whether its episodes can differ in intensity for an individual. Additional studies and research in this area would be sensible and desirable. It would also be good if women were treated holistically in all areas of gynecology and obstetrics. This means that during pregnancy and childbirth management, the consequences of interventions performed in the postpartum period should also be considered.
At this point, I would also like to emphasize that Slovenian professional terminology, at least in this area, is quite weak. There were many difficulties in translating certain phrases. One of them, for example, is: “milk ejection reflex” or “let down.” Since I could not find an adequate translation anywhere, I translated the phrase as “refleks iztekanja mleka” (milk ejection reflex). It would be excellent if more work were done in this area in the coming years and if efforts were made to supplement the professional dictionary in this field.
Read more:
Use of medications during childbirth and their impact on women and breastfeeding
Milk Let-down or Milk Ejection Reflex
Breast changes during breastfeeding and lactogenesis
Hormones important for breastfeeding
Breastfeeding in the delivery room
9 instinctive phases of the newborn
Source: Diploma thesis “Women’s Experience and Feelings During Breastfeeding” (2016) by Teja Šircelj under the mentorship of Lecturer Tita Stanek Zidarič, Dipl. Midwife, MSc, IBCLC
