By Lynnea Nicholls, DO
Editor’s Note: Lynnea Nicholls, DO, wrote this article during her fourth year of medical school while participating in the FACTS elective , where she deepened her understanding of fertility awareness-based methods (FABMs) and their clinical applications. For this article, Dr. Nicholls interviewed a first-time mother who chose to use the Lactational Amenorrhea Method (LAM) postpartum and explored how breastfeeding patterns, return to work, and emerging signs of fertility shaped the mother’s experience with the method. In recognition of National Breastfeeding Month, her story highlights the close relationship between breastfeeding and fertility awareness and the value of helping women understand how lactation influences the return of fertility and how to transition to another FABM.
“Ava,” a nurse and first-time mom, chose to use the Lactational Amenorrhea Method (LAM) because she wanted a non-hormonal option for managing fertility immediately postpartum. She appreciated that LAM had clear qualification criteria: amenorrhea, fully or nearly fully breastfeeding, and less than six months postpartum.[1][2][3] Prior to pregnancy, Ava had been using the Natural Cycles app while also self-monitoring for mucus. She planned to return to this method after LAM.
When Ava first considered what “exclusive or near-exclusive” breastfeeding would look like in real life, initially she thought LAM meant no pacifiers or bottles at all. However, after more research, she learned that official guidance focuses on amenorrhea plus near-exclusive feeding plus the six-month timeframe.[1][3] Many official sources add practical guardrails like keeping feeding intervals at four hours or less during the day and six hours or less at night to help maintain the hormonal suppression that powers LAM.[2][3] Knowing the science behind the importance of maintaining prolactin levels and the difference in prolactin response to breastfeeding and mechanical pumping gave her confidence to use the occasional pacifier or bottle. Direct feeds and/or well-timed pump sessions are helpful to succeed with LAM.[4][5][6]
“Initially, Ava thought LAM meant no pacifiers or bottles at all. However, after more research, she learned that official guidance focuses on amenorrhea plus near-exclusive feeding plus the six-month timeframe.”
By 10 weeks, Ava’s baby sometimes slept 7 to 8 hours straight. She experimented with a dream feed or a quick pump around the 6-hour mark because the longest “stimulation-free interval” is when many people from online forums noted decreased confidence in the method.
Ava’s maternity leave was 12 weeks long, and she did eventually return to work. Her breaks were inconsistent, sometimes pushing her longest interval past 6 to 7 hours, and there was often not a pumping room available. Around month four, she noticed the return of egg-white cervical mucus and a twinge of “mittelschmerz,” which she had previously experienced with ovulation. Ava and her partner treated that window as potentially fertile. Her menses returned the following cycle.
Ava’s experience aligns with the evidence that employment and limited work support are major barriers to exclusive breastfeeding moms.[7][8] LAM’s high effectiveness is time-limited to six months and sensitive to real-life adherence.[1][9]
With Ava’s return to work, she noticed how stress, hydration, and skin-to-skin contact influenced let-down and supply.[10][11] Importantly, Ava began experiencing D-MER (Dysphoric Milk Ejection Reflex)—brief waves of dread associated with milk letdown—in the early weeks after returning to work. Learning that D-MER is due to a transient dopamine shift accompanying milk ejection helped her name it, normalize it, and keep breastfeeding while using LAM.[12][13]
“Ava began experiencing D-MER (Dysphoric Milk Ejection Reflex)—brief waves of dread associated with milk let-down—in the early weeks after returning to work.”
A review of Ava’s health history didn’t reveal any red flags that might have complicated her use of LAM. She had no history of thyroid disease, PCOS, postpartum hemorrhage, or retained placental fragments—which are all conditions that can affect the timing of fertility’s return due to hormonal changes and decreased milk supply. These conditions can create confusion, decrease the effectiveness of this method, and require further workup and treatment.
Ava’s story emphasizes LAM criteria, including having amenorrhea, fully or near-fully breastfeeding, and being less than six months postpartum. These criteria help families focus on one simple thing to track: how long it’s been since the last feeding or pumping session. Watching that number over time gives families a clear picture of how they’re doing. Second, it prepares couples for the changes that may alter the effectiveness of the method, such as longer stretches of sleep at night, going back to work, starting pacifiers, and introducing solid foods. These shifts often happen right before fertility signs like cervical mucus return. Third, her story shows the importance of not ignoring signs of D-MER in breastfeeding mothers. When mothers know there’s a name for those brief feelings of dread during milk letdown, it can be a huge relief and help them keep breastfeeding if that’s what they want. However, it may also be important to dig deeper to distinguish between D-MER and postpartum depression or anxiety. Finally, helping mothers plan in advance for the fertility-tracking method they intend to use once fertility returns can provide clarity and confidence during this transition.
“It prepares couples for the changes that may alter the effectiveness of the method: longer stretches of sleep at night, going back to work, starting pacifiers, and introducing solid foods. These shifts often happen right before fertility signs like cervical mucus return.”
*Note: Names have been changed to respect the privacy of the interviewee. All information is shared with permission.
REFERENCES
[1] Centers for Disease Control and Prevention. Appendix G: Lactational Amenorrhea Method. U.S. Medical Eligibility Criteria for Contraceptive Use. Updated November 19, 2024. Accessed September 10, 2025. CDC
[2] American College of Obstetricians and Gynecologists. Postpartum Birth Control. Updated April 2023. Accessed September 10, 2025. ACOG
[3] World Health Organization; Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs. Family Planning: A Global Handbook for Providers. 4th ed. 2022. Accessed September 10, 2025. World Health Organization
[4] Meier PP, Patel AL, Hoban R, Engstrom JL. Which breast pump for which mother: an evidence-based approach to individualizing breast pump technology. J Perinatol. 2016;36(7):493-499. doi:10.1038/jp.2016.14. PMC
[5] Hopkinson JM, Heird WC. Maternal response to two electric breast pumps: a randomized trial. Breastfeed Med. 2009;4(1):17-23. doi:10.1089/bfm.2008.0133. PubMed
[6] Chatterton RT Jr, Hill PD, Aldag JC, Hodges KR, Belknap SM, Zaldivar FJ. Relation of plasma oxytocin and prolactin concentrations to milk production in mothers of preterm infants: influence of stress. J Clin Endocrinol Metab. 2000;85(10):3661-3668. doi:10.1210/jcem.85.10.6912. Oxford Academic
[7] Widström AM, Lilja G, Aaltomaa-Michalias P, et al. Skin-to-skin contact the first hour after birth, underlying neurophysiology, and its effects. Acta Paediatr. 2019;108(7):1192-1204. doi:10.1111/apa.14754. PubMed
[8] Uvnäs-Moberg K, Ekström-Bergström A, Buckley S, Massarotti C, Pajalic Z, Luegmair K, et al. Maternal plasma levels of oxytocin during breastfeeding—A systematic review. PLoS One. 2020;15(8):e0235806. doi:10.1371/journal.pone.0235806. PLOS
[9] Van der Wijden C, Manion C. Lactational amenorrhoea method for family planning. Cochrane Database Syst Rev. 2015;2015(10):CD001329. doi:10.1002/14651858.CD001329.pub2. PubMed
[10] Centers for Disease Control and Prevention. 5 Tips for Returning to Work and Breastfeeding. Published April 18, 2025. Accessed September 10, 2025. CDC
[11] Ray R. Individual and organizational factors associated with breastfeeding practices in employed mothers. Workplace Health Saf. 2023;71(8):375-383. doi:10.1177/21650799231167580. PubMed
[12] Heise AM, Wiessinger D. Dysphoric milk ejection reflex: a case report. Int Breastfeed J. 2011;6:6. doi:10.1186/1746-4358-6-6. BioMed Central
[13] Deif R, Burch EM, Azar J, Yonis N, Abou Gabal M, El Kramani N, DakhlAllah D. Dysphoric milk ejection reflex: the psychoneurobiology of the breastfeeding experience. Front Glob Womens Health. 2021;2:669826. doi:10.3389/fgwh.2021.669826. frontiersin.org
ABOUT THE AUTHOR
Lynnea Nicholls, DO, is a Family Medicine resident at St. Anthony Family Medicine Center Orchard in Westminster, Colorado. She earned her Doctor of Osteopathic Medicine degree from Rocky Vista University College of Osteopathic Medicine in Parker, Colorado, after completing her undergraduate education at the University of California, Berkeley.
Dr. Nicholls has a particular interest in women’s health and preventive care. She completed the FACTS elective during her fourth year of medical school to deepen her understanding of fertility awareness-based methods and natural family planning, with the goal of equipping future patients to make informed decisions about their reproductive health
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