Dysphoric milk ejection reflex: an overlooked syndrome affecting up to one in five breastfeeding women

Dysphoric milk ejection reflex (D-MER) is a syndrome characterized by a sudden onset of negative emotional experiences occurring a few seconds prior to each ejection of breast milk. These sensations arise and resolve abruptly, typically lasting only several minutes, and recur with every individual milk let-down. As a result, women affected by D-MER may experience dozens of such episodes throughout the day and night. According to available studies, D-MER affects approximately one in ten to one in five breastfeeding women. The specific emotional experiences vary among individuals in type, intensity, and duration. While some mothers experience symptoms throughout the entire breastfeeding period, in others the symptoms resolve spontaneously after several months, most commonly after approximately three months. Reported emotional states include insecurity, sadness, irritability, aggression, panic, shame, self-loathing, and depressive mood; in rare cases, suicidal ideation has also been described. Additional accompanying symptoms include loss of appetite and impaired concentration. D-MER has a neurobiological basis. The pathophysiology of this syndrome remains a subject of research. The most supported hypothesis is because prolactin, a hormone essential for milk ejection, is tonically inhibited by dopamine. For prolactin levels to rise sufficiently, a reduction in the level of its inhibitor must first occur. A transient decrease in dopamine is therefore considered a likely mechanism underlying the negative emotional changes characteristic of D-MER. There is no available causal therapy. Current evidence suggests that awareness of D-MER itself, together with practical measures such as drinking ice-cold water, getting adequate sleep, and ensuring privacy during breastfeeding, may help reduce the subjectively perceived intensity of symptoms. Education and basic awareness can therefore represent an important source of support for many women.