As a breastfeeding counselor who aspired to become an IBCLC I felt I was pretty "up" on all the breastfeeding issues a mother could face while lactating. So when I was pregnant with my third child I figured as long as the homebirth went without a hitch, it would be smooth sailing from there, and it was, at first. The birth was a fairytale and my babymoon was like a dream. Then the babymoon came to an abrupt end as I started to find that just before my milk released, each and every time, I had an overwhelming sensation of guilt, dread and horror. I didn't have any pain, no physical problems, just a surge of negative emotions that hit me in the gut out of nowhere, only to fade away a few moments after my milk released from my breast. I felt great otherwise. Happy as a clam in our new home that I had nested to perfection, a husband who was home for five weeks and family near by to support me.

Only, I had this horrid feeling every time I nursed, and in between with spontaneous letdowns. I never experienced this with my first two. Nor had I ever heard about anything like this in my lactation training. I could tell it was some hormonal misfire that left me reeling. Was I the only one? How come I hadn't heard about it? Could I tell anyone about it? Dare I tell anyone about it? What would they think.....?

I did tell someone about it, actually I told everyone that would listen to me. By sharing my story I found hundreds of other mothers just like me and we all found out that it didn't have a name and no one knew why it happened. So in turn I pounded on virtual doors and found big name lactation professionals who stood up and took notice of us several hundred mothers and helped me investigate this phenomenon, this phenomenon that no one was talking about.

Breastfeeding's best kept secret is a condition affecting lactating women that is characterized by an abrupt dysphoria, or group of negative feelings, that occurs just before milk release and continues not more than a few minutes. It's called Dysphoric Milk Ejection Reflex (D-MER) and it seems to be more prevalent among breastfeeding women than anyone would have imagined.

D-MER was an unnamed condition prior to the beginning of 2008. The phenomenon is not necessarily news in itself. In a few small online communities it has been discussed between breastfeeding mothers, those that actually chose to breastfeed in spite of it and were brave enough to ask about it. Among lactation professionals it was occasionally brought up, but always quickly dismissed: it was "just one mother" or "we're not sure what causes it, we just know it happens, but rarely" or "Were you sexually abused? Did you want this baby? Did you have a traumatic birth experience?" But no one made the effort to explore exactly how many women were affected or to investigate the cause...until this year. It turns out it's not psychological at all. It's 100% hormones and chemicals and an honest-to-goodness physiological condition.

When a breastfeeding mother has D-MER, usually beginning about one week into lactation, about with the onset of lactogenesis II or III, she begins having a brief surge of negative emotions that precedes her letdown. It is not necessarily caused by mouth to nipple contact; it happens whenever the milk ejection reflex is triggered; by conditioned reflex (undoing the bra clasp or hearing the baby cry), nipple stimulation (by infant or expression of milk), or with spontaneous letdowns. This emotional reaction happens suddenly and intensely in a strong wave that then dissipates after the milk has released from the breast. Depending on the intensity of D-MER it can then repeat with each subsequent letdown.

This is a condition that is set far apart from postpartum depression. In fact, most D-MER mothers have no postpartum mood disorders at all, but actually feel very happy and normal, until an MER is triggered. These emotions then suddenly surge upon her, in a most unjustified manner, causing her to feel confused as to why she feels this way, alone as the only mother feeling this way while nursing, like a bad mother for her emotional reaction and, even though a few minutes after milk release she feels okay again, it gives her an overall very unpleasant breastfeeding experience. She lives in a world where she dreads the next feeding because she will need to battle intense and nebulous emotional demons along with it.(1) It is an emotional rollercoaster that a breastfeeding mother with D-MER repeats 9-15 times a day.

When the investigation of D-MER began it started with simply finding and acknowledging that a vast number of breastfeeding mothers experienced it. What was so surprising is that every one of them thought she was alone in her experience, because no one was talking about it. Why did these mothers not come forward and ask "What is wrong? It should not be this way"? Probably because the message that is sent out to new mothers is that they should feel warm, fuzzy, loving, and maternal when they nurse. So when a breastfeeding mother instead feels dark, cold, and hostile when she nurses, it generally leaves her feeling like a "weirdo" a "freak" or a "bad mother." Mothers also knew that if they brought these feeling into conversation with a professional they would be questioned about their psychological state. However, every mother who experiences D-MER believes it is hormonal. She has an innate sense inside herself that it has something to do with her body, not her mind. This is what the investigation of D-MER uncovered, and as it was further researched those mothers were proven correct. Mothers have not known D-MER as to be something that is not their fault until recently and the information is still so new that the majority of mothers still don't know that they are not alone or to blame in their experience. This hesitation, embarrassment, fear and guilt they have because of this is what has kept them from speaking about it and this has caused the phenomenon of D-MER to become breastfeeding's best kept secret.

A few points repeatedly come up when D-MER is discussed. One is, "Why does everyone have to feel good all the time? Why is it such a bad thing that a mom feels a little sad when she nurses? Maybe D-MER is a variation of a normal breastfeeding experience." Well, evolutionarily it makes sense to have pleasurable emotions released, not despairing ones(2), when milk lets down. These emotions too, are not always just a little sadness; these are no "letdown blues." For many women it can include intrusive thoughts, suicidal ideation, and other intense emotions. These are emotions that come completely out of nowhere for a D-MER mother. She can be loving life one moment, sit down to nurse, and feel like dying the next. Then she is right back up again. It's extremely exhausting and disconcerting for a mother, especially because right now most mothers have no idea what or why they are experiencing. Some say that women are defensive about D-MER not being a psychological problem. "What's wrong with having a psychological problem?" they ask, "We all have them." Nothing is wrong with having a psychological problem, unless everyone is telling you that you have one when you don't. It is also important to know whether D-MER is psychological or hormonal because solutions will not be found if they are sought in the wrong direction. Some D-MER mothers have spent a year or more pursuing ineffective treatment and counseling.

The research into D-MER is very new, based mostly on anecdotal evidence so far. Now that it is gaining profession-wide acceptance, more scientific approaches and studies are being formed. Preliminary tests indicate that the drop in dopamine that happens with the start of an MER is most likely to blame for the negative reaction in D-MER mothers. A drop in dopamine apparently happens in all lactating mothers with milk release, because prolactin can't rise unless dopamine drops.(3) However in mothers with D-MER, dopamine seems to fall inappropriately, either too fast or too far, or there is an issue with the dopamine receptors. Dopamine's correlation to mood and its effect on the pleasure center of the brain is widespread knowledge4 and when dopamine doesn't act as it should, it can cause a dysphoric reaction.(5)

D-MER presents on a spectrum with three different levels and has been broken down into three different intensities; mild, moderate and severe. Level one is a depressive level, often manifesting in emotions such as dread, sadness, worthlessness or hopelessness. Level two is an anxiety level with emotions such as anxiousness, irritability or panic being most prevalent. Level three is the rarest of the three and is often anger based, with feelings of agitation, aggressiveness and hostility. D-MER manifests as an emotional reaction , and though these emotions often include "in the mother's stomach" - a hollow feeling, a feeling of something in the pit of the stomach, or an emotional churning in the stomach, D-MER is not nausea with letdown or any other isolated physical symptom (eg. headache, itching nausea, etc.) with letdown. A mother may have physical manifestations in conjunction with D-MER, but D-MER itself requires an emotional response.

D-MER can easily go unrecognized since 1) some mothers have so many closely spaced letdowns per feeding that the feelings do not have a chance to dissipate before the next D-MER is upon her, making her feel that she experiences one long D-MER through most of, if not all of, the feeding 2) many mothers do not physically feel a letdown in their breasts and so do not connect the feeling with letdown and 3) given the fact that D-MER happens with spontaneous letdowns as well, a mother may not immediately connect the way she is feeling with a breastfeeding phenomenon. It is also very likely that D-MER has been misinterpreted as PPD in the past and mothers have been misdiagnosed.

For some mothers D-MER self-corrects by three months. For other mothers it continues past the first year, sometimes going away only with weaning. Some mothers find that, after learning their emotions are being artificially simulated with letdown and that they need not evaluate their position in life every time they nurse, they can cope with D-MER without treatment. Still other mothers find the feelings to be stronger and harder to dismiss, and seek natural treatment options and lifestyle changes that can help balance their dopamine fluctuation. A woman with severe D-MER may find that her mood swings and downward plunge with letdown affect her so intensely that natural treatment is not enough and she needs a prescription, one that increases her dopamine, in order to make her D-MER less disruptive.

The investigation of D-MER is ongoing, but awareness and education are one of the top priorities. Mothers need to know they are not alone and are not to blame. They need to know that there are treatment options. Professionals need to know that D-MER is physiological and that a mother cannot fix her D-MER with cognitive readjustment. It's time to open the door on breastfeeding's best kept secret and make D-MER a widely known and recognized condition.

More information, resources and support for D-MER for mothers, lactation specialists and prescribing care providers can be found at www.d-mer.org.

Alia Macrina Heise is postpartum doula and a CLC who is planning on sitting for the 2010 IBCLC exam. As a lactation specialist and a former sufferer of D-MER she is part of the D-MER investigation team and is responsible for running www.d-mer.org. She lives in the Finger Lakes region of New York State with her husband and three children.

Alia Macrina Heise, CLC, PCD(DONA)
www.d-mer.org
info@d-mer.org