What does the research tell us about Dysphoric Milk Ejection Reflex?

What is Dysphoric Milk Ejection Reflex?

The latest research studies, summarised below, tell us that Dysphoric Milk Ejection Reflex (DMER) a surge of negative emotion which directly relates to the experience of milk letdown, starting from a few seconds prior and lasting for just a few minutes. DMER is quite different to postnatal depression and anxiety. There is no link with nipple pain. Most women with DMER find that it is either milder or not evident with pumping. Almost half cease breastfeeding altogether because of DMER. DMER is not an indication for pharmaceutical treatment, including selective serotonin reputake inhibitors.

Ureno et al 2019

We used to say that DMER was rare. Then in 2019 a retrospective review of medical records at a US military hospital found that 9% of breastfeeding women had self-identified as having had a negative emotional response to their milk ejection reflex when they came in for their 6-8 week check after having a baby. After this, although we still don't know its true prevalence, due to definition problems, the health system began to treat DMER more seriously.

Cappenberg et al 2025

Definitions

Dysphoric milk ejection reflex DMER is a surge of negative emotions concurrent with a milk letdown. DMER has a paroxysmal, characteristic temporal association with the milk ejection reflex.

Methodology

This study was an online cross-sectional survey on the experience of DMER in German women who had a child 18 months or younger, and who had fed that child with breast milk for any length of time.

Findings

Of 1469 respondents, 209 (14.2%) had experienced DMER.

The DMER women used the following words to describe their experience of DMER: tense, hypersensitive, frustrated, irritable, overwhelmed, sad, lonely. Of the DMER women,

• 85.9% had used a pump to express. 57% of those pumping experienced milder or no DMER symptoms while pumping.

• 40.2% of the DMER group found the symptoms remained stable between birth and weaning.

The factor which worsened DMER symptoms were stress and lack of sleep. Loneliness and conflict with a significant other were also frequently cited as worsening DMER symptoms. The factors most likely to ease DMER symptoms were support from their partner and sleep.

Middleton et al 2025

Definitions

Breastfeeding aversion response (BER) and DMER are two examples of breastfeeding phenomena which present as negative emotional experiences of breastfeeding and lactation, but which are considered physiological in origin.

• DMER is the sudden onset of dysphoria prior to and during milk ejection.

• BAR is unpleasant feelings and physical sensations during breastfeeding.

Background

Many women self-diagnose with DMER and BAR and seek online support. Being believed helps women cope. Self-care alleviates both DMER and BAR. DMER and BAR are associated with range of negative emotions which impact breastfeeding. Much remains unknown about both.

Health professionals may reach inaccurate conclusions especially if women have pre-existing mental health conditions. Health professionals commonly misdiagnose DMER or BAR as postnatal depression or anxiety.

Both phenomena are distinct from perinatal mood disorders. Some suggest hormonal shifts as the causes.

A patient is quoted as follows: "I wanted to keep on breastfeeding, but ... I also ... didn't want to ... it is a ... fight inside me every time."

Method

This study is a scoping review 116 academic and grey literature records.

Findings

DMER

The rate of DMER estimates varied from 6-28% of women.

Participants with DMER reported a hollow feeling ranging through anxiety, sadness, and anger to rage and suicidal ideation. Some women with DMER describe nipple pain during milk ejection, nausea, food revulsion, extreme thirst.

There are two dominant hypotheses concerning the aetiology of DMER.

1. DMER results from a brief drop in dopamine which occurs during milk ejection triggers DMER

2. DMER results from the release of oxytocin prior to milk ejection.

Mindfulness, relaxation and skin-to-skin contact with the baby helped alleviate the intensity of DMER.

BAR

BAR was found in 23% of participants.

BAR most commonly affects pregnant women, women breastfeeding older infants, and women who tandem feed.

BAR manifests as feelings of agitation, disgust, irritability and tingling and skin crawling, which only occur during breastfeeding. Some women with BAR describe skin-crawling, tingling, prickling, throat tightening, and gut-wrenching sensations. Intrusive thoughts affect some women postnatally but BAR relates specifically to the breastfeeding act, which distinguishes from perinatal mood disorders.

BAR has been framed by some as “an evolutionary mechanism to protect parental resources and increase the chance of further ... reproduction”.

Howard et al 2025

Aim

The aim of this study was to determine the prevalence of DMER and mental health correlates in a cohort of patients from a breastfeeding medicine clinic.

Background

Range of prevalence of DMER is reported at 6–28% of breastfeeding women. One study showed an increased risk for DMER in patients with prior psychiatric diagnoses but this study did not have a strong methodology. The authors note that there is a confounding between symptoms of DMER and depression which confuses the interpretation of existing studies.

Method

This study was a retrospective analysis of answers given in the DMER question of 271 patients' intake questionnaires in a breastfeeding medicine clinic in North Carolina, USA.

Findings

The overall patient patient characteristics in this study were

• Average 11.5 weeks postpartum

• White and non-hispanic

• Most were pumping (86.3%) as well as directly breastfeeding

• 36.9% were supplementing with formula

• 7 in 10 women reported pain with breastfeeding

• Typical presenting complaints include difficulty with infant latching, inadequate milk supply, and pain with breastfeeding.

The DMER patient characteristics showed

• 15.5% of the patients studied screened positive for DMER.

• Breastfeeding pain and pumping did not predict DMER symptoms.

• Those reporting DMER were more likely to have a self-reported history of panic attacks. Of these

  • 81% described anxiety symptoms associated with milk let down

  • 54.8% reported depressive symptoms.

• 8-45% of DMER patients had already quit breastfeeding.

This study found DMER symptoms were more common in those who had reported a history of panic attacks but there wasn’t an increased incidence noted with other self-reported mental health diagnoses including depression, anxiety, postpartum depression.

Solmonovich et al 2024

Aim

To determine DMER incidence, and to describe symptom profiles and patient characteristics. DMER is described as brief, abrupt, negative emotions experienced by breastfeeding individuals prior to milk letdown.

Method

This is a prospective observational study of 55 patients who initiated breastfeeding after delivery in two hospitals in New York City. Participants filled out an Initial Survey, and recurring DMER Symptoms Surveys.

Findings

The incidence of DMER was 26.9%, with symptoms severity mostly very mild to moderate.

The only difference with other patients initiating breastfeeding was a higher rate of caesarian section.

The authors stated that DMER likely has a physiologic basis influenced by environmental stressors and psychological context, noting that there are two explanatory hypotheses:

1. Oxytocin, which is normally calming, may paradoxically upregulate the stress response resulting in DMER.

2. Abnormal flucations in dopamine levels with increased prolactin levels during breastfeeding result in DMER.

Zutic et al 2024

Aim

This study aimed to validate an instrument for DMER related emotions.

Method

711 women up to 12 months postpartum participated in an online cross-sectional study. They filled out a DMER Questionnaire, which was shown to have high reliability and good discriminant and divergent validity, as well as other mental health and infant bonding scales. [Note: external validity of this questionnaire has yet to be established.]

Findings

• Prevalence of DMER was 5.9%

• For the majority, DMER manifested intensely, accompanied mostly by angitation and anxiety-related emotions

• 45% of mothers discontinued breastfeeding due to DMER

• Mothers with DMER had higher levels of depression, anxiety, stress, previous psychiatric diagnoses, and more mother-infant bonding difficulties.

Ureno et al 2019

In another part of the study I mentioned above, 99 breastfeeding women were recruited who identified as having negative emotions just before milk letdown, when latching, and/or pumping. These women were predominantly college educated, white, and living with a husband. Their experience of D-MER was categorised according to their selections from the following word lists to fill in the sentence “I feel ____ just before my milk lets down”. In the category 'agitation', they selected from irritable, agitated, tense, annoyed, impatient, frustrated. In the category 'anxiety', they selected from anxious, panicky, restless, fearful, paranoid. In the category 'despondent', they selected sad, oversensitive, tearful, homesick, worthless, guilty, lack of family.

80% reported feeling happy between letdowns. But the group rated their current stress level as 3, on average, on a scale of 1 to 5. Three-quarters of the women also reported a history of anxiety, depression or both. 16% had taken antidepressant or anti-anxiety medication during pregnancy; 14.1% were diagnosed with postnatal depression. 50% reported that lack of sleep and stress exacerbated the symptoms, and 99% reported that these D-MER feelings came on suddenly and for no apparent reason.

Recommended resources

Do you have Dysphoric Milk Ejection Reflex?

What the research DOESN'T tell us about Dysphoric Milk Ejection Reflex and the risks associated with unnecessary use of this diagnosis

Do you have Breastfeeding Aversion Response?

What does the research say about Breastfeeding Aversion Response?

References

Cappenberg R, Garcia JG, Liolios I, Happle C, Scharff AZ. Dysphoric Milk Ejection Reflex: prevalence, persistence, and implications. European Journal of Obsetrics and Gynecology 2025;308:127-131.

Deif R, Burch EM, Azar J. Dysphoric Milk Ejection Reflex: the psychoneurobiology of the breastfeeding experience. Frontiers in Global Women's Health. 2021;2:doi:10.3389/fgwh.2021.669826.

Howard M, Goulding AN, Muddana A, Fletcher TL, Cirino N, Stuebe AM. Dysphoric milk ejection reflex: prevalence and associations with self-reported mental health history. Archives of Women's Mental Health. 2025:https://doi.org/10.1007/s00737-00025-01571-00734.

Middleton C, Lee E, McFadden A. Negative emotional experiences of breastfeeding and the milk ejection reflex: a scoping review. International Breastfeeding Journal. 2025;20(13):https://doi.org/10.1186/s13006-13024-00692-13003.

Solmonovich RL, Kouba I, Bailey C. Incidence and awareness of dysphoric milk ejection reflex (DMER). Journal of Perinatal Medicine. 2025;53(2):258-261.

Ureno TL, Berry-Caban CS, Adams A, Buchheit TL, Hopkinson SG. Dysphoric Milk Ejection Reflex: a descriptive study. Breastfeeding Medicine. 2019;14(9):666-673.

Zutic M, Matijas M, Rados SN. Dysphoric milk ejection reflex: measurement, prevalence, clinical features, maternal mental health, and mother-infant bonding. Breastfeeding Medicine. 2025;20(2):DOI: 10.1089/bfm.2024.0172.

This page was last updated 20 June 2025