Navigating dysphoric milk ejection reflex: Implications for maternal mental health

Search strategy

A structured search was conducted using the search engine Google Scholar and four databases: PubMed, EMBASE, SciELO, SCOPUS and PsycINFO. Keywords such as “DMER,” “dysphoric milk ejection reflex,” “lactation,” “maternal mental health,” and “breastfeeding” were employed to refine the results. Filters for English and Spanish languages and publication years (2010–2024) were applied.

Inclusion criteria

Studies reporting data on prevalence, symptoms, management, prevention, and sociocultural perspectives were included in the study. Studies were excluded if they were conducted on animals or did not specifically approach DMER.

Study selection

The initial search generated 136 results [Figure 1].^[17] Fourteen duplicates were removed using an automation tool, leaving a total of 122 articles to be screened for title and abstract. After the first screening, 78 articles were excluded, leaving 44 articles. Three articles were further excluded as the full text was not available, leaving 41 to be assessed in full text for eligibility. A total of 29 articles were excluded as they did not meet the inclusion criteria, leaving a total of 12 eligible studies to be included in this narrative review.

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Figure 1:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram illustrating the search and selection process.

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Social perspective on breastfeeding

DMER is present not only as a physiological phenomenon but also as a social experience deeply influenced by societal norms and pressures surrounding motherhood and breastfeeding. Breastfeeding is often idealized, mothers who experience negative emotions like those caused by DMER may face stigma, guilt, and shame, affecting their mental well-being.^[16,18] In addition, the expectation that breastfeeding should be a natural and joyful experience can amplify the emotional distress of mothers with DMER, making them feel wistful and develop self-loathing.^[19] These stressors can lead to a sense of failure or inadequacy, further exacerbating mental health issues such as mood disorders, which have been reported to be intertwined with DMER.^[13,15]

Thus, understanding DMER requires recognizing the broader social and cultural context that shapes a mother’s experience with breastfeeding and the implications of this phenomenon, as addressing these psychosocial factors through targeted interventions and increased awareness can help reduce the burden associated with DMER.

Cultural approaches to breastfeeding

Cultural influences play a significant role in shaping how women approach breastfeeding. A 2012 study found that beliefs, such as that women cannot have sex while breastfeeding, breastfeeding during pregnancy is harmful, breast milk spoils if the mother spends time away from the infant, and that infants will reject other foods if introduced after 6 months, negatively affect adherence to evidence-based recommendations.^[20] Despite these convictions, there is still an expectation for mothers to breastfeed, as formula feeding is often viewed as abnormal, especially among religious communities.^[20]

This expectation is so strong that some religious women (Christian and Muslim) have reported secretly feeding their infants alternative foods while lying about it to their peers to meet societal demands.^[20]

In rural areas, there is a belief that exclusive breastfeeding causes excessive crying, which leads to the early introduction of other foods before the recommended 6-month mark to keep the baby “healthy.”^[20]

These contradictory demands place significant strain on mothers, increasing their risk of other mental health issues, particularly if they develop DMER. A study conducted in Japan revealed that women experiencing DMER often did not seek help, believing no one would understand their symptoms or that they could not sufficiently explain them.^[12] Cultural beliefs surrounding motherhood and breastfeeding further complicate the identification and management of DMER, leaving affected women without adequate support or coping mechanisms.

Impact on mental health

DMER significantly impacts maternal mental health,^[21] often exacerbating feelings of guilt, anxiety, and isolation. Mothers with DMER report experiencing sudden, overwhelming negative emotions such as sadness, agitation, or anxiety during milk ejection, which can lead to increased psychological stress.^[19,22] These emotional responses can be misunderstood by both the mothers and healthcare providers, limiting the access to support.^[16] In addition, some women report avoiding discussing their symptoms due to fear of judgment or dismissal, further complicating their emotional distress.^[15]

Common emotions associated with DMER include tension, exhaustion, irritability, hypersensitivity, and restlessness.^[20] Factors such as insomnia, stress, and breast fullness have been found to worsen DMER symptoms.^[20] Rather than seeking professional help, many women use coping mechanisms such as distraction, focusing on their baby, resting, spending time alone, drinking cold water, listening to music, talking to others with similar experiences, or, in some cases, stopping breastfeeding altogether.^[12,20] However, stopping breastfeeding has been linked to increased risks of depression and anxiety,^[23,24] further exposing mothers to negative mental health outcomes.

Treatment options

Treating DMER requires a multidimensional approach that addresses both its physiological and psychological components. Since DMER is linked to a sudden drop in dopamine during milk ejection, some treatment strategies involve stabilizing dopamine levels. Medications such as bupropion, a dopamine reuptake inhibitor, have shown promise in alleviating symptoms.^[9,19] However, pharmacological interventions remain limited, and more research is needed to establish effective treatment protocols. Non-pharmacological treatments also play a key role, with relaxation techniques, narrative, psychodynamic and cognitive-behavioral strategies helping mothers manage the emotional distress associated with DMER.^[10] Mindfulness, deep breathing and grounding exercises have been suggested to reduce anxiety and improve emotional regulation during breastfeeding.^[8] Support networks are also critical; connecting mothers with others who have experienced DMER, either through peer groups or counseling, can help reduce feelings of isolation.^[11]

Finally, educating healthcare providers about DMER is essential to ensure proper treatment,^[11] as many mothers report feeling misunderstood by medical professionals, further complicating their care.^[16] A combination of medical, psychological, and social support interventions offers the most comprehensive approach to managing DMER.