What is Dysphoric Milk Ejection Reflex (also known as DMER)?

Is it possible that you're experiencing Dysphoric Milk Ejection Reflex, often referred to as DMER?

DMER is a wave of distressing negative emotion, such as anger or dread or extreme anxiety, which starts a few seconds before your milk letdown happens. It can happen with either direct breastfeeding or pumping. DMER might also be accompanied by nausea or a hollow or churning feeling in the pit of the stomach. These feelings last for a few minutes, while the letdown continues, and generally for no more than five minutes.

DMER happens only with the letdowns, not at other times. It might occur on a spectrum of intensity, from mild to severe, and sometimes eases off with subsequent letdowns in the one feed. The unpleasant feelings might also come with distressing thoughts, typically the way when we have upsetting feelings - including (for a small number of women) thoughts about self-harm.

How common is DMER?

We used to say that DMER was rare. Then a study 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, the health system began to treat DMER more seriously.

What should you do if you have DMER?

Here are the steps I recommend if you are concerned you may be experiencing DMER.

1. See your doctor to confirm the diagnosis.

2. Some women report that DMER becomes less intense the older the baby is and the longer you've been breastfeeding, although for other women DMER stays much the same right throughout. If you have severe DMER, you may decide it's best to wean and feed your baby either with formula or donated human milk, so that you and your baby can enjoy milk times together. Or you may decide to cut back on the frequency of breastfeeds, supplementing with donated human milk or formula.

3. If you have DMER but decide you feel able to continue breastfeeding for now, you could practice managing upset and unhelpful thoughts as you make room for unpleasant bodily experience of emotions. These are powerful psychological strategies which derive from Acceptance and Commitment Therapy (ACT).

   • Trying to get rid of the distressing thoughts and feelings that sweep through your body with milk ejections can actually make them a lot worse. It's important to know how to deal those awful thoughts and feelings, even as you accept that they are going to be there whenever you have milk ejections.

   • Although ACT hasn't been researched for DMER, the tools of ACT (e.g. cognitive defusion, experiential acceptance) have been demonstrated in many studies now to be very effective with other conditions, including chronic pain management and phobias, which involve powerful somatic responses to specific events.

4. You could stop drinking coffee to see if this helps. Some have suggested that coffee might amplify any aversive response to letdowns in some women.

5. I recommend avoiding pharmaceuticals for the management of DMER. There is no evidence to support medications (such as selective serotonin reuptake inhibitors) for DMER, and no sensible biological rationale for their use. DMER is quite separate to mental health challenges of depression and anxiety or other mental health diagnoses, since it is limited specifically to your body and mind's response to the physical event of milk ejection.

Sometimes, you might find it possible to manage and minimise the awful feelings and thoughts that sweep through you with letdowns, using ACT strategies. I have had women report to me that this has worked well for them, and eventually the DMER passed. Other times the experience is so intense that a woman may decide, with deep self-compassion, to wean.

Can DMER be misdiagnosed?

Sometimes, women are misdiagnosed with DMER even though they have nipple pain throughout some or all of the breastfeed. Pain is often associated with nausea and strong aversive emotions. However, whilst breastfeeding pain is a serious problem which requires skilful health professional assistance, it is different to DMER. The underlying reasons for the pain or unpleasant physical sensation should be urgently addressed. You may need to take a break from direct breastfeeding or even from pumping if your nipple pain is debilitating, as you seek help from breastfeeding support professionals.

Sometimes women are misdiagnosed with DMER when they are experiencing an intense and physical dread of breastfeeding, either because of nipple pain or because the baby becomes upset at the breast. It is normal and protective to dread breastfeeding when breastfeeding hurts you, or when your baby consistently becomes distressed at the breast. This dread tells us there is a serious problem which requires skilful health professional assistance, but is a different experience to DMER.

Recommended resources

Do you have Breastfeeding Aversion Response?

What does the research say about Breastfeeding Aversion Response?

What does the research say about 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

Selected 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.