medical tomfoolery

A Very Milky 101

I enjoy lactation. This is my own personal space, so no single one of you cowards can stop me from saying that very brazenly, perversely, but also curiously. I've long had a fascination with lactation as a function of the human body, both because I find it very hot for reasons that I could not even begin to psychoanalyze, but also because I think the human body's capacity to produce a wide array of fluids for a wide array of purposes is pretty interesting. Milk just happens to be the most interesting to me because it tastes nice, it's full of nutrition, and it's incredibly important to our development.

But you don't need another person to tell you the benefits and functions of breast milk when it comes to raising youths. [1] Especially as someone who is neither a lactation consultant or a breastfeeding mother. Maybe I'll be one of those some day - or perhaps both! - but as it stands, my interest with lactation presently stems entirely from how I find it to be very erotic in sexual contexts, and very gender-affirming in non-sexual contexts. For this reason, I've wanted to induce lactation for a very long time, which is a... curious process, as I've discovered.

First off, let's address the question that people always seem to posit about trans women lactation: can you even do that?
Well, if the fact that I wake up with sore breasts every morning and am capable of sweetening and creaming my own coffee at 8AM is any indication, yes. Yes they can. Hormone replacement therapy leads to our breasts developing akin to how AFAB people develop theirs during puberty [2], and this (presumably, anecdotally, albeit scientifically contested [3]) can be further augmented by the addition of progesterone to a feminizing hormone regime in the latter stages. We have all the correct components to do it: and cisgender man can as well. You can find the occasional story of a cis man taking medications and ending up with leaky milkers. [4]

This leads to our key question: Wait, what medications?
My dear curious reader, we have quite a bit to explain. Medications that affect lactation are referred to as galactagogues, and the mechanism through which many function is by raising the levels of the protein prolactin. Prolactin, as the name implies, is the protein which precedes milk production. It serves a number of other functions as well, but the key purpose of prolactin it seems is to trigger milk production within the human body once the concentration of it reaches a high enough level. [5] There seems only to be a few triggers for producing that concentration however, and most of it is quite closely tied to bodily processes during pregnancy. For instance, prolactin production is greatly stimulated by a sharp drop in levels of the feminizing hormone estradiol. [6] This occurs during the final stages of pregnancy, where estadiol levels can reach above 15,000pg/ml, before sharply dropping below 100pg/ml after giving birth. [7]

While we could potentially simulate that by ingesting ludicrous amounts of estradiol in a short period [8], that would be a horrific idea. So what are our other options? We could also inject pure prolactin, but this is a terrible idea too because it has an absurdly short half-life. [6] Another choice may be to take extreme amounts of progestins (artifical forms of the hormone progesterone), but this comes with a lot of health risks. [9] Lastly, we could just do nipple stimulation until something happens, but inducing lactation exclusively through this is pretty difficult [source: the pain in my tits after months of trying]. There's some other choices too, I'm sure, but for the sake of not bogging this page down more than it already has been, I'm going to cut to the one which has proven to be the most reliable over the years: dopamine suppression.

The main class of medication that's used to induce lactation are dopamine receptor antagonists, here-on abbreviated as DRAs. DRAs, as their name implies, are medications which block dopamine from binding to dopamine receptors. [10] If your familiarity with dopamine as the 'feel good' chemical is leading you to suspect these medications may have serious effects on mental health, you aren't entirely wrong. The most common types of DRAs are anti-psychotics, such as risperidone and haloperidol, which have very pronounced mental effects and are often used to treat depression, schizophrenia, and other mental health disorders. No one seems to know exactly how this works, but there's theorizing that certain mental health disorders may be influenced by dopamine levels, and thus dopamine receptor antagonism helps to rebalance things.

Dopamine is Stored in the Tummy, and I've Got a Tummy Ache

However, dopamine doesn't exist exclusively within the brain. Dopamine receptors exist all over the body, including in the stomach, where it is understood to affect some gastric functions in some capacity. [11] For this reason, the medication domperidone exists. Domperidone is a DRA which is believed to not cross through the blood-brain barrier [12] and, therefore, exhibits little to no effect on the mental health of people who use it. (However, there is theorization that at high enough dosages it may penetrate it. We'll talk about this later. [13]) Its' effects are almost if not entirely exhibited within the stomach of the user, where it is associated with improvements in nausea, vomiting, and gastroparesis. [14] As an aside, I have long had serious issues with debilitating stomach pain and sudden nausea, and I did not realize until I started taking domperidone just how nice it felt not to be plagued by those problems. I thought it was normal!

At any rate, we are not interested at this moment in the stomach effects of domperidone. What we are interested in, as a bunch of perverts curious about breast milk, is that it's capable of suppressing dopamine without causing any mental health effects (again, probably). This matters to us because dopamine has a very funny relationship to prolactin, wherein it acts as an ihibitor. Therefore, suppression of dopamine leads to a rise in prolactin. [15] As in, a big rise. [16] If you're a poor lad taking domperidone because you're constipated all the time, or taking risperidone to clear your brain, then this happening to you might feel like a form of body horror (or sudden gender euphoria, maybe even both). As someone who wants to lactate though, this is pretty awesome.

For this reason, domperidone has been more-or-less the de-facto medication for people interested in inducing lactation. This includes not just adult breastfeeding fans and breast perverts like myself, but mothers struggling to produce milk as well. [17] To make matters even better, domperidone is quite easy to access depending on where in the world you live in -- and how internet savvy you are. I live in a nation that is truly free, Brazil, and unlike in the locked down state of the United States, I can just walk into the pharmacy and say "ah bom dia! eu gostaria de comprar uma caxinha de domperidona, por favor, obrigada," and ten minutes later, I have 60 10mg pills of domperidone in hand. In other countries however, domperidone can be somewhat harder to access, with the US in particular having more or less banned the medication due to medical concerns (we'll get to this shortly). [18]

So, what does a lactation inducing regime of domperidone look like? Well, that really depends on the individual. The Newman-Goldfarb protocol is the classic procedure from which the usage of domperidone for lactation originates (at least to my knowledge), and NMGF calls for prospecting people to take - by the end - 80mg per day (20mg x 4). [19] This has become one of the defaults in the adult breastfeeding community in my experience, alongside 90mg per day (30mg x 3). Some people go even higher, pushing it past the 120mg mark. For comparison, the recommended max therapeutic dosage for gastric issues is 30mg per day (10mg x 3) [12], and some (contrary to Dr. Newman of the NMGF protocol [20]) argue there is no reason to go beyond this [21]. Some swear by their higher regimes, but others seem content with lower amounts. I, personally, am in the latter camp. I began with taking 30mg every day, and this has resulted in me - who has C-cup breasts - being able to produce 30ml every 4 hours. While that isn't quite enough to feed a 2-month old child (which expects at least 120ml typically [22] ), it's definitely enough for lactation play and adult breastfeeding, and I'm perfectly content with it.

A Chat About Safety

DISCLAIMER: I AM NOT A DOCTOR, DO NOT TAKE WHAT I'M SAYING AS AUTHORITATIVE.

Throughout this, I've been making little hints about potential health concerns with taking domperidone. This is not just me slyly attempting to keep you reading, but gestures to actually point to something important. Domperidone is, at the end of the day, a medication, and like all medications, it has potential side effects. By far the one that I've seen reported in breastfeeding spaces the most is nausea, which I suppose isn't quite surprising given what the medication effects - perhaps for those who do not have any nausea issues, the medication can trigger them by throwing off balances of dopamine in the GI system? While I haven't experienced this myself, I'm also not on a very high dosage of the medication, and I had pre-existing stomach issues anyways.

What is more concerning to me are the reports people make of depression, anxiety, and general mental stability difficulties. This is particularly pronounced when ceasing to take domperidone, in which a small portion of people report very severe side effects bordering on psychosis. [20][23] I have read every single paper I possibly can on domperidone with regards to lactation, and these issues are scarcely mentioned, let alone speculated on. To further complicate things, every academic report I could find of mental health issues related to domperidone were related to post-partum women. If you are not aware, the post-partum period of pregnancy is associated with quite a lot of bodily and hormonal changes [24], which makes it extremely difficult to separate issues caused by domperidone with regular ol' "pregnancy is a severely traumatic event for the body and mind and the fact we don't allow people to end the process at will is a crime against already living humans" thing. [25]

The working theories I've seen for this:

1: Domperidone at very high doses may cross the blood brain barrier, contrary to prior understandings. [13] The paper that brings this up does not provide any concrete evidence, and instead theorizes. I think it's worth investigating further as there is hardly a body of research on lactation-inducing domperidone dosages, but I also wonder if it's knocking on the wrong door to begin with. A friend I was discussing this topic with said something along the lines of 'anyone who's used psychoactive drugs before will tell you the bodily experience is half of the experience.' Given how much gut health influences our body, I don't think it's wrong to presume that perhaps lowering dopamine in the gut might fuck with the body more broadly, even if the brain isn't directly affected in the same way it would be with, say, risperidone.

2: Sudden cessation of domperidone causes a sudden change in prolactin and/or dopamine levels, which may cause psychiatric events. [16]This theory makes the most immediate sense to me, presuming that the sudden increase in dopamine also affects the amount in the brain. Given that we know dopamine has an effect on psychiatric events, a sudden shift in it causing psychiatric issues would make sense. However...

As I was looking into all this in a panic-induced stupor, stuck between "god I want to lactate" and "god I don't want to feel like killing myself trying to lactate," I came across a website containing the accounts of various pregnant women who took domperidone and reported serious side effects when ceasing it. [27] One of them had mentioned that they got their hormones tested by their primary care provider, and came back with a very interesting result: they had practically no estradiol in their body. Now, for a post-partum woman, this isn't too surprising, because post-partum levels can get to post-menopausal levels (which is to say, basically no estradiol in the body). [28] However, this got me to thinking: could prolactin have some sort of effect on hormones?

Turns out, yes, prolactin does in fact have an effect on other hormones in a round-about way. Prolactin is said to suppress production of follicle-stimulating hormone (FSH) and lutenizing hormone (LH) [29], which are hormones the body later converts into various androgens (such as testosterone and DHT), estrogens (such as estradiol), and progestogens (such as progesterone). [30] As any woman who has been through menopause can tell you (or any transgender woman who has been put on absurd anti-androgen doses), being without hormones absolutely fucking sucks and causes serious mental health problems including depression, anxiety, and - yes - even psychosis. [31]

I won't armchair diagnose anyone who has struggled with domperidone withdrawl with a hormone deficiency, but I really feel like the FSH/LH inhibitory effects of prolactin should be mentioned to people who are looking to induce lactation, because if this theory is correct, it could explain a lot. In fact, one study was done on pre-menopausal women taking anti-psychotics, which DID find a correlation between raised prolactin and lowered estrogens and worse mental health therefore. [32] But, I am not a doctor, so I may be off my rocker here, and I also I feel I really have to emphasize that reports of these effects are incredibly rare.

In Conclusion

Honestly, inducing lactation has been a pretty fun experiment for me. It's felt very fulfilling and affirming in ways I didn't expect it would, and many ways I expected it to. I also went up a cup size which is pretty sick. I've long wished I could have at least C-cups without having to go through breast augmentation surgery, and this gave me those much desired C-cups. I still wish I could go bigger, but I'm at the point where I really can't be bothered to pay and don't think I'd get much happier from it.

I've also had a lot of fun figuring out what the heck to do with all this milk. I don't produce a lot, but 30ml every few hours is still quite a bit to go through. So far I've been using what I have in the morning to supplement regular dairy milk to great success, and I've also been looking at how to donate milk. Sadly, not much luck on that front. One of the two local donation drives turned me down due to being too far out of their pick up area (but not for being trans, yay for no transphobia!), and the other one doesn't have such great reviews online. Maybe I'll give it a try at some point, or I'll just tell people I can donate milk if they need it. At any rate, it's been fun, and I look forward to updating this page with more random bullshit.

Sources

[1] https://www.ncbi.nlm.nih.gov/books/NBK52687/
[2] Reisman et al, A Review of Breast Development in Cisgender Women and Implications for Transgender Women, 2019
[3] https://transfemscience.org/articles/progestogens-breast-dev/
[4] https://transfemscience.org/articles/transfem-lactation-literature/#cisgender-men
[5] https://www.ncbi.nlm.nih.gov/books/NBK507829/
[6] https://www.ncbi.nlm.nih.gov/books/NBK537331/
[7] https://www.hormona.io/blog/estradiol-levels-chart/
[8] https://estrannai.se/#i0__cu,50,4,1
[9] https://transfemscience.org/articles/transfem-intro/#progestogens
[10] https://apm.amegroups.org/article/view/1039/html
[11] https://www.sciencedirect.com/science/article/abs/pii/S156607022200100X
[12] https://www.drugs.com/domperidone.html
[13] https://pmc.ncbi.nlm.nih.gov/articles/PMC3962062/
[14] https://pmc.ncbi.nlm.nih.gov/articles/PMC8636553/
[15] https://pubmed.ncbi.nlm.nih.gov/18477617/
[16] https://pmc.ncbi.nlm.nih.gov/articles/PMC9121093/
[17] https://www.childrens.health.qld.gov.au/health-a-to-z/medicines/domperidone-breast-milk-supply
[18] https://www.fda.gov/drugs/investigational-new-drug-ind-application/how-request-domperidone-expanded-access-use
[19] https://www.canadianbreastfeedingfoundation.org/induced/regular_protocol.shtml
[20] https://www.cbc.ca/news/canada/domperidone-breastfeeding-side-effects-1.6673093
[21] https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-024-07027-4
[22] https://www.parents.com/baby/feeding/baby-feeding-chart-how-much-and-when-to-feed-infants-the-first-year/#toc-1-to-3-month-old-feeding-schedule
[23] https://pubmed.ncbi.nlm.nih.gov/36367713/
[24] https://www.mayoclinic.org/diseases-conditions/postpartum-depression/symptoms-causes/syc-20376617
[25] https://pmc.ncbi.nlm.nih.gov/articles/PMC10733854/
[26] https://www.hsa.gov.sg/announcements/safety-alert/potential-risk-of-psychiatric-withdrawal-events-with-domperidone-for-stimulation-of-lactation
[27] https://sites.google.com/view/domperidone-syndrome/home
[28] https://www.frontiersin.org/journals/global-womens-health/articles/10.3389/fgwh.2024.1428494/full
[29] https://pubmed.ncbi.nlm.nih.gov/6776267/
[30] "Emerging insights into Hypothalamic-pituitary-gonadal (HPG) axis regulation and interaction with stress signaling," Rodrigeuz et al
[31] https://www.sciencedirect.com/science/article/pii/S2773021224000063
[32] https://link.springer.com/article/10.1007/s00737-024-01491-9