Dysphoric milk ejection reflex
Dysphoric Milk Ejection Reflex (D-MER) is an anomaly of the milk release mechanism in lactating women. A lactating woman who has D-MER experiences a brief dysphoria just prior to the milk ejection reflex.
Presentation of D-MER
The lactating woman who has D-MER experiences a brief period of dysphoria that begins just prior to the milk ejection reflex and continues for not more than several minutes. It may recur with every milk release or only with the initial milk release at each feeding. D-MER always presents as an emotional reaction but may also produce a hollow or churning feeling in the pit of the stomach. When experiencing D-MER mothers may report any of a spectrum of different unpleasant emotions, ranging from depression to anxiety to anger. Each of these emotions can be felt at a different level of intensity. (LLLI 2010)
Spectrum and intensity
Women who experience D-MER can experience a wide range of negative emotions that fall on what is referred to as the Spectrum of D-MER. These emotions usually fall under three categories, including despondency, anxiety and aggression. The D-MER spectrum of emotions can occur at any of several intensities, without changing the type of emotion. For example, a woman may experience a sense of depression and this feeling can range from mild homesickness or wistfulness to more intense feelings of hopelessness and self-loathing. Similarly, anxiety may range from restlessness to more intense panic and dread. Anger, the least likely of the three, may range from tension and agitation to more intense feelings of hostility and aggression.
Mechanism of D-MER
The mechanism is not clear. In a mother with D-MER, dopamine may fall inappropriately with milk release, causing the negative feelings. Among the hormones involved in milk production and release are oxytocin, prolactin, and dopamine. Oxytocin, released in pulsatile "spikes" from the posterior pituitary in response to nipple/areolar stimulation, thoughts of the baby or of breastfeeding, or overfull breasts, travels through both brain and bloodstream, causing emotional changes in the brain and the release of milk in the breast. Prolactin, released in a gradual wave that peaks after the beginning of a feeding, is responsible for continued milk production. Dopamine inhibits the release of prolactin, so dopamine levels must drop in order for prolactin levels to rise. Some speculate that the necessary dopamine drop is similar to (and timed with) the oxytocin spike – a sort of negative image – but that in D-MER mothers it drops either too far or somehow differently, causing a negative emotional reaction as a result  This mechanism is speculative. What is known is that, at least some of the time, supporting dopamine levels reduces D-MER in susceptible mothers.
Misconceptions about D-MER
- D-MER does not appear to be a psychological response to breastfeeding. It is possible for women to have psychological responses to breastfeeding, but D-MER gives evidence of being a physiological reflex. 
- D-MER is not nausea with letdown or any other isolated physical manifestation that happens with letdown (hives, headaches, thirst, etc.) Some D-MER mothers may also have a churning in their stomach that can cause a brief aversion food and even water, but D-MER always includes an emotional manifestation. 
- D-MER is not postpartum depression or a postpartum mood disorder. A mother can have D-MER and PPD, but they are separate conditions and the common treatments for PPD do not treat D-MER. The majority of mothers with D-MER report no other mood disorders. 
- D-MER is not the "breastfeeding aversion" that can happen to some mothers when continuing to nurse while pregnant. Breastfeeding aversion occurs upon nipple contact when nursing whereas D-MER is triggered by the let-down reflex, even if it is several minutes after latching.
Management of D-MER
What has been shown to be effective to eliminating D-MER is anything that raises and maintains dopamine. There are a variety of foods, herbal medications and prescription options that do this, but not all of them are appropriate for the condition or for an otherwise healthy breastfeeding mother. At this time there is no product that is medically approved to treat D-MER. However, treatment is rarely needed.
Emotional Support and Validation
The most effective treatments for D-MER found thus far are awareness, understanding, and education. Many mothers with D-MER rate their D-MER much worse prior to learning what is causing their feelings . Once a mother understands that she is not alone in her condition and realizes it is a physiological condition she seems to be much less likely to wean prematurely.  Because of the overwhelmingly positive effect of awareness and connection with other "D-MER mothers," much energy has been put into educating mothers and lactation professionals about the condition. D-MER is an increasingly common topic for presentations at lactation seminars in Europe and Australia ; interest in the US is also growing. D-MER.org holds much of the information currently available on D-MER. Also available through the website are an online media presentation on YouTube, a Facebook group with a message board and a Facebook page that sends links to the latest online information about D-MER to members’ news feeds.
Identification and Description
The first documented reference to a hormonally based negative emotional reaction while breastfeeding was found online in a forum in June 2004 . Prior to the launch of D-MER.org the phenomenon was unknown, unnamed, misunderstood and rarely mentioned or talked about. The term dysphoric milk ejection reflex (D-MER) came from Alia Macrina Heise who was the first to identify and describe the phenomenon to lactation professionals in 2007. It was chosen due to the emotional reaction (dysphoria) to milk let-down (milk ejection reflex). The "milk ejection reflex" is abbreviated among lactation professionals and referred to as the M-E-R. This means that D-MER is not said DEE-MERE, but rather D.M.E.R, all the letters names said individually. In 2008 a team of lactation consultants, headed up by Diane Wiessinger, MS, IBCLC, LLLL worked together and consulted with other medical professionals to do a preliminary investigation to better understand D-MER.  After the first published case study of D-MER  it became a more widely known and accepted condition.
Recognition of D-MER
D-MER has been mentioned in a few breastfeeding text and self-help books since 2010 and awareness of this anomaly is steadily growing across the internet. References to D-MER can be found in blogs, Twitter and even reddit. However, as of March 2014, there has been no scientific research studies involving mothers who experience D-MER to support the hypothesis that it is caused by the drop in dopamine just prior to the milk ejection reflex. There is a strong argument for this hypothesis in the original case study.
Books that Mention D-MER
- Breastfeeding Answers Made Simple: A guide for Helping Mothers By: Nancy Mohrbacher 2010 
- Breastfeeding (Seventh Edition) 2011 By: Lawrence, R. A. (Chapter 16 p. 550-613)
- The Womanly Art of Breastfeeding 8th Edition. By: La Leche International (p. 416)
- The Nursing Mother's Companion 6th Edition By: Kathleen Huggins 2010 (p. 171) 
- Lawrence and Lawrence. Breastfeeding: A Guide for the Medical Professional, 2010
- Heise, Alia Macrina. Opening the Closet Door on D-MER, DONA International, 2008
- Wiessinger, Diane. D-MER, What Is It?, Breastfeeding Today 2010
- Cox, Suzanne. A Case of Dysphoric Milk Ejection Reflex, Breastfeeding Review 2010; 18 (1): 16-18
- Heise, A. M., Wiessinger, D. "Dysphoric Milk Ejection Reflex: A Case Report" International Breastfeeding Journal. 2011
- Mohrbacher, N. "Breastfeeding Answers Made Simple: A guide for Helping Mothers" Hale Publishing. 2010.
- Lawrence, R. A., Lawrence, R.M., "Breastfeeding A guide for the Medical Profession" Saunders. 2011. Chapter 16. P.550-613
- La Leche International "The Womanly Art of Breastfeeding 8th Edition" La Leche International. 2010. p416
- Huggins, K. "The Nursing Mother's Companion 6th Edition" Harvard Common Press. Boston, Massachusetts. 2010. p. 171
- Is It Psychological from d-mer.org
- Nausea when breastfeeding on Kellymom.com
- Depression or Other Negative Emotions upon Milk Let-down (D-MER)
- Bad Feelings During Breastfeeding: D-MER on Postpartum Progress
- Quote from Mothers on d-mer.org
- Mothering.com Community
- LC's Concur from d-mer.org
- La Leche League International. "The Womanly Art of Breastfeeding", Ballantine Books, 2010. ISBN 0-345-51844-6
- Specifics of D-MER from d-mer.org
- Quotes from Mothers on d-mer.org
- Branch of the Australian Breastfeeding Association Seminar Topics
- Shining Light on Dysphoric MER in Breastfeeding Women on YouTube
- Is it normal to feel like crying when breastfeeding? on BabyZone
- When breastfeeding causes bad feelings on Motherwear.com Blog
- D-MER, or feeling crappy when your milk lets down on Ask Moxie
- 500 or More with D-MER, a Facebook group with message board specifically for mothers with D-MER
- A Facebook page that provides that most current online information about D-MER