For a period of every month, I'm completely miserable

February 24, 2010 6:34 AM

This is a question about menstruation. You have been warned.

Once upon a time, I had nice, polite periods. They were short (3-4 days), light, and did not inconvenience me in any way. Three and a half years ago my son was born. Since then, my periods have been a complete disaster - helped along by ten months on blood thinners following a post-surgical DVT. Now my period lasts 7-8 days, is painful, and is enormously heavy and messy. I routinely pass very large (think superball-sized, and larger) clots or masses of tissue - often multiple times in a day, and because of the clots I have intense cramping Its not unusual for me to soak through a pad in a couple of hours. This morning (the first overnight of my period) I woke up to discover that I had completely filled and soaked a 14" long extra heavy overnight pad, soaked through my underwear, my pjs, and the sheets. My son likes me to co-sleep with him, but I can't during the first few days of my period, because I don't want him to wake up to this mess.

I have been off the blood thinners for nearly a year. My Primary Care doctor (male) seemed to think that my periods would return to "normal" by now. My midwife (who I see of GYN stuff also) says "well, sometimes your periods are different after a baby" and doesn't think its anything unusual - that this is just the "new normal" for my body.

I hate it. I'm miserable, in pain, and now find my periods to be totally disgusting (which I never did before). I cannot take any hormonal birth control (so to stop them entirely) due to the DVT in my medical history. My flow completely overwhelms a cup, and I can no longer use tampons due to vaginal damage I sustained during the birth, so I'm stuck with pads and this enormous mess.

My questions: Did this happen to you? Did your periods change radically post-childbirth? Is this, in fact, normal? If your periods are like mine, how do you cope? Should I consider a D&C to try and reduce the size and frequency of clots? Or do I just have to accept that this is the "new normal" and suck it up and deal? Will getting an IUD help, or make things worse? Is the ANYTHING I can try (herbs, acupuncture, drugs, anything) to make my periods go back to the way they were?

Thanks for your help!

posted by anastasiav to health & fitness (37 answers total)

IANAD(Y), but aren't progesterone-only options okay for women who have a history of DVT? Somethnig like Depo-provera or Mirena or Norplant might work to eliminate periods.
posted by greatgefilte at 6:42 AM on February 24, 2010 [1 favorite]

Of course, you should always get a second opinion if you feel your body is completely out of whack. But I had nice, crampless, pretty periods before my son was born, too. I actually thought women might be exaggerating PMS.*

Post-childbirth, torrential, heavy, clotty, crampy awful periods. They have gotten slightly better over time and after having a second child, but they seriously changed in every way and it did become new normal.

Naproxen seems to work the best for my cramps; don't take aspirin while you're on your period as it's a blood thinner and just makes things worse. Heating pads help, too.

*I'm really sorry! I was 18 and stupid!
posted by headspace at 6:51 AM on February 24, 2010

Re the IUD, unfortunately, I think you would need the hormonal IUD (Mirena is what it's called in Canada) to see any effect on your period (I've had a Mirena for about 3 years, and my period has pretty much disappeared). My understanding is that the non-hormonal IUDs tend to make one's period heavier and crampier. Sorry. :(
posted by purlgurly at 7:00 AM on February 24, 2010

I don't have children, but this happened to several of the women in my family after childbirth. Some of them have lately been diagnosed with endometriosis.

IANAD, but while it may be normal to undergo changes in your cycle after childbirth, and while it might even be common to experience heavier and more painful periods after childbirth, that doesn't mean you should just suck it up and deal with it without seeing what your options are.

In terms of the IUD suggestion, you might consider a Mirena IUD. It is progesterone-only; I use it because my migraines preclude the use of estrogen-containing birth control, and other progesterone-only methods made me sick. Mirena tends to result in an overall thinning of the uterine lining, so the flow will be less heavy. Some people experience more cramping with Mirena, though. (I haven't had a period since a few months after my IUD was inserted, but I do get some cramping at the times when I would expect a period to take place.)

Do NOT get a Paragard (copper-containing) IUD in the hopes of normalizing your period. Those IUDs tend to increase both menstrual flow and cramping in women who get them.
posted by kataclysm at 7:00 AM on February 24, 2010

That being said, if greatgefilte is correct, the Mirena only contains a low dose of progestin, so maybe it would be okay for you? More information is here.
posted by purlgurly at 7:02 AM on February 24, 2010 [1 favorite]

For the last seven or eight years that I had periods (before I had a partial hysterectomy - my ovaries and cervix were retained), I had periods like you describe. Clots like that looked like pieces of liver, terrible cramps, flooding ...

After trying several different types of drugs (the names of which I can't remember now, I'm afraid) over a number of years, none of which worked, I decided to draw a line under the whole thing and have a hysterectomy, because I was mid-40s, I had great health insurance and benefits at work to allow me full recovery time off on full pay.

But if I hadn't gone that route, I probably would have had the next thing that was on my gynae's list to try, which was endometrial ablation.

It might be worth asking your gynaecologist about it.
posted by essexjan at 7:02 AM on February 24, 2010 [1 favorite]

Oops - here. Sorry for the multiple posts.
posted by purlgurly at 7:03 AM on February 24, 2010

Have you tried disposable underpants from the incontinence section instead of pads? I thought they were lifesaving for lochia, much better than shifty sticky leaky pads. (FWIW as a data point, this was not one of my many unpleasant postpartum surprises; periods stayed about the same.)
posted by kmennie at 7:04 AM on February 24, 2010

A non-hormonal IUD will probably not make things better -- anecdotal evidence suggests that the plain copper IUD will make periods heavier and longer. Mirena, which is a hormonally supplemented IUD (but as greatgefilte says, progesterone-only), will tend to make periods shorter and lighter because of the hormones.

My understanding is that you can be prescribed progesterone-only options even with a history of DVT when the benefits outweigh the theoretical risks. That likely might be the case in your situation.

I would go back to your PCP and tell him that, since your periods have not returned to normal, you want to explore your options. (It's not clear from your post whether your PCP has suggested a D&C, etc., or if those are just options you are aware of from your own research.)

IANAD.
posted by devinemissk at 7:08 AM on February 24, 2010

I am not a doctor or a mother, but I do have very heavy, long lasting, extremely annoying periods. Your description sounds more annoying than my usual, but not really by much. Definitely take this to a doctor and don't just accept it, but in the meantime, a few things that have helped me deal with my own problems over the years:

First and foremost, I can't recommend them enough, the Always Infinity pads are like MAGIC. I wouldn't care if they were made out of adorable baby seals, I would use them still. You linked to the Always Overnight ones, and I'm unsure if they use the same materials as in the Infinity pads, but I used to use ones that looked like your link, before the Infinity ones were being made, and they don't hold a candle. It completely soothed my ongoing fears of bleeding all over in a public place. Those things do a number on the thin, runny stuff, and actually somehow dry up the clots so they don't shift. Additionally they feel better - maybe the moisture wicking properties reduce irritation, I don't know, but personally they feel more like cotton than any other pads I've tried.

Going to sleep when you're worried about waking up to bloody sheets is horrible and I commiserate. This is going to sound kind of weird, but don't wear pants. Look, it's bad enough when you have to wash your underpants in the sink, but with pajamas and so-on, you're looking at a load of laundry. Plus, it's easier to tell in that state of half-sleep if you've got an actual problem, or you're just dreaming about it, if you're not trying to feel that sinking sensation of blood against the leg with flannel pants in the mix. Also, make sure that your panties are a little bit tight. Go a size smaller than you otherwise would, if you can. This will keep things from shifting around at night, a lot more than you might think, and the elastic around the edges can serve as a barrier for leaks. It's up to you to decide if the occasional nighttime wedgie is worth it. Sometimes, when I'm going especially strong (yaaay) I will literally go to sleep on a towel. Truly, don't be ashamed. Our bodies are strange conglomerations and never promised to be convenient about anything.

Lastly, always have supplies on-hand. Every purse, every interior coat pocket, every backpack and toiletry bag I own, heck, even the bathrooms of my very good male friends, all have a secret supply of pads in them. I stash them everywhere, so if I'm out and about and it turns out to be a heavy day, I can confidently change every couple of hours and not run out until evening. I don't just restock when I'm due, either. They're always there, just in case.

I'm sure lots of people will have suggestions for you on the medical side of things, but in the meantime, know that other woman do cope with periods like yours, and you can make your life a little less awful in the interim.
posted by Mizu at 7:11 AM on February 24, 2010 [5 favorites]

When my periods changed in a way very similar to yours, it turned out I had fibroid tumors. I wasn't seeing a GYN at the time, just my GP who had always taken care of my lady bits, too. She let the bleeding go on far too long without further diagnostics, and it made things much more complicated for me down the road. So if you haven't had an ultrasound... you should consider asking for one. The "wait and see" thing is bullshit.
posted by kimdog at 7:12 AM on February 24, 2010 [1 favorite]

I, of course, ANAD. I do, however, have endometriosis, which is what I first thought of and kataclysm mentioned. The other thing that came to mind is fibroid tumors. At any rate, what you are describing is NOT normal - periods involving bleeding as heavy as you've described, clots, and painful cramps are something that need to be checked out by a gynecologist.
posted by noxetlux at 7:17 AM on February 24, 2010

I ended up with stage three endometriosis after having just the symptoms you described being ignored for years despite my complaints. I went to another doctor over the issue, leaving the Ob who had delivered both my children.

And I couldn't be happier that I did, because I learned that you don't have to just suck it up and suffer. At one point my ovaries were twisted and one was fused to the fallopian tube because of the Endo (we thought the cramps/pain were ovarian cysts at the time), and that's when we ended up going down the route to the hysterectomy.

All this horror story graphicness is my effort at getting you to either be more assertive with your own doctor and midwife or find someone who will listen to you and treat the problems you are having aggressively so you don't end up where I did. Endometrial ablation may be an option for you (it wasn't for me), but you shouldn't have to go through this every month. Do something about it NOW.
posted by misha at 7:29 AM on February 24, 2010

Yes, fibroids or polyps can cause this-- see your doctor, a D and C may well help.
posted by Maias at 7:30 AM on February 24, 2010

FWIW, my SO was once prescribed Depo-Provera with disastrous results.

DP does tend to have more side effects because of the kind of progesterone used. I'm told that the progestin-secreting IUD, Mirena, is a lot better in that respect. (Not a shill for Mirena, but a lot of my ob/gyn profs are big fans of it.)
posted by greatgefilte at 7:37 AM on February 24, 2010

It doesn't matter if this is "normal" or not. Maybe it is, maybe it isn't. But you're miserable, and that needs to be addressed. If you need to see more sympathetic doctors, I'd start asking around, because you shouldn't have to endure this.

I have had a D&C, and here was my anecdotal experience: It made my periods enormously more bearable. They were so short, so light, so ignorable. It took about a year for them to even approach the previous blood volume I'd been experiencing. If your doctor decides this is an option for it, I recommend it.

You shouldn't get an IUD, for the reasons outlined above. But I want to point that that copper IUDs do not necessarily cause people to endure worse cramping and bleeding, if they are willing to try the Occiblu Ibuprofen Remedy.
posted by Coatlicue at 7:53 AM on February 24, 2010

oh, and to clear up the thing about hormonal vs. non-hormonal IUDs:

- The horrific side-effects of Depo-Provera, as detailed by xndr, are the same problems that I had with other systemic progesterone-only methods (i.e. the mini-pill). Norplant could also cause these side effects. But it's important to remember that the Depo shot is a ridiculously huge dose of hormone, and even Norplant and the minipill, while the doses are smaller than Depo, contain a larger dose than Mirena. That's because they're all methods for delivering hormones to the entire body; in order to affect the reproductive system, you need to put a lot of hormone into your bloodstream when you're giving a systemic dose. If you can locally dose the reproductive system itself, you don't need to give as much drug to the whole body.

- Mirena contains a synthetic progesterone, just as Depo does. However, the hormonal IUD is a local dose of progesterone -- it releases a very small amount of hormone directly into your uterus, which all the progesterone receptors in your reproductive organs grab onto -- the amount of progesterone circulating around in your bloodstream doesn't really increase. Therefore, you're much less likely to have the weight gain, depression, acne, etc. that are common side effects of systemic progesterone. Case study of one: I gained about 50 pounds on the pill, and also had horrible breakouts on my face, gross stringy hair, and wicked fits of depression. I went on Mirena, and I lost all the weight, my face and hair cleared up, and I am not depressed. So, a lot of doctors will prescribe Mirena where they would be hesitant to prescribe other progesterone-containing contraceptives, because the dose is so small that it has pretty much only local effects.
posted by kataclysm at 7:55 AM on February 24, 2010 [4 favorites]

I have periods like yours. They didn't get that bad immediately after childbirth - they were fine until about 8 years after my daughter was born and have gotten increasingly worse since. I had a D&C a couple of years ago, which helped initially, but after a few months my periods returned to "normal", which means they last 10-15 days, 5 of which are as heavy as you describe. I have been diagnosed with adenomyosis, which happens when the uterine wall thickens due to endometrial tissue moving into the walls of the uterus. My symptoms are so severe that I am a good candidate for hysterectomy, which I am seriously considering because spending half the month bleeding sucks.

My suggestion is to go to an OBGYN who specializes in dealing with endometriosis and other uterine abnormalities. You could have fibroids, endometriosis, adenomyosis, or just a jerk of a uterus that wants to ruin your life, but you need to see a specialist to find out which.

And the Always Infinity pads mentioned upthread ARE magical. Try them. They will help.
posted by bedhead at 7:57 AM on February 24, 2010 [1 favorite]

Not saying one is better than the other, but I was the Depo shot for 4 years and LOVED it. My period went away completely. I may have gained a few pounds while on it, but other than that I had no side effects whatsoever. Which, honestly, I didn't give a shit about the barely noticeable weight gain as long as my painful periods were gone. The only reason I got off of it (just recently) was to get it out of my system (it takes awhile), as the hubs and I are thinking of having a baby in the nearish future.

Of course, reading all of this is giving me second thoughts...
posted by elisebeth at 7:58 AM on February 24, 2010

Make sure you're eating enough vitamin K, the lack of which can cause excessive bleeding, menstrual or otherwise. Don't take vitamin K as a pill; just be careful to eat enough vitamin-K-rich foods to meet the recommended intake. You're supposed to consume 90 micrograms a day, an amount that is easy to reach if you make a habit of eating an ordinary serving size of leafy green vegetables, such as spinach or any dark green type of lettuce, every day or two.

One reads that vitamin K deficiencies are rare, but when my mom had a minor cut and continued to bleed for far too long, in spite of not having had a bleeding disorder before, it turned out to be due to a vitamin K deficiency. She'd been avoiding the green vegetables she liked because her doctor had told her they'd exacerbate her gout, and the only lettuce she'd been eating was iceberg lettuce. The problem was quickly corrected.
posted by Ery at 8:06 AM on February 24, 2010

I'm also not a doctor or a mother, but I am concerned about your potential for anemia. Consider an iron-fortified multivitamin or adding iron-rich foods to your diet.
posted by jgirl at 8:09 AM on February 24, 2010 [1 favorite]

2nd Mizu on the towel. Get a couple of cheap, darkly-colored ones that don't match your other towels (purple, maroon) and just sleep on top of them. They're easy to wash, you don't have to change the sheets, you can move around in your sleep without worrying, and if they're dark they don't show stains. (And if they don't match, you won't confuse them with other towels!)

If you're reasonably regular, my doctor always recommended starting Aleve/naproxen the day BEFORE your period is due to start; something about how the drug works (how it binds to receptors or something?) is better if it's in there before the cramping begins. (She explained it, I do not remember it.)
posted by Eyebrows McGee at 8:10 AM on February 24, 2010

When my periods changed in a way very similar to yours, it turned out I had fibroid tumors.

Me too. I complained to my GP about it and she did a pelvic exam to investigate, and found that my uterus was bigger than it should be -- either from pregnancy or something else. I had an ultrasound done and it was a giant fibroid. I later had it removed because I was bleeding as heavily as you are.

Definitely get it checked out; it could be any number of things. Good luck.
posted by sutel at 8:21 AM on February 24, 2010

I used to have very unobtrusive periods as well (4-5 days, maybe a couple hours of cramps, only one day of heavy flow). I got pregnant last August and had miscarriage in September, with a D&C to follow. The next period after was VERY light, and I was like "Awesome, if this is the new normal, I am totally down with this." Unfortunately, after that month, it was heavier than it had ever been. Not quite to the level you're dealing with, but definitely noticeably worse.

This is all just to say that a D&C is not necessarily a permanent solution. It's possible they would have leveled out over the year, but I just found out I'm pregnant again, so who knows.
posted by chiababe at 8:24 AM on February 24, 2010

My periods got much heavier and clottier in my early 30s, with no noted change in anything else, no pregnancy or birth control switch or anything. Not as bad as what you describe, I don't think, but definitely a notably different experience from my menstrual cycle in my 20s.
posted by mdn at 8:37 AM on February 24, 2010

Oh yes, Eyebrows McGee is right about the Aleve the day before your period. I have no idea about the science behind it, but generally I can tell if my period is going to be a painful one and Aleve ahead of time really takes the edge off. Also to assist with the pain, you have heating pads, various yoga poses, hot baths and showers, and making sure your posture is good when you're at your job, sitting or standing. I would also be concerned about anemia and just general nutrition; most of the times when my period is extra terrible it's because I haven't been treating myself right, so don't hesitate to have that extra helping of vegetables or get yourself to bed earlier than usual. Every little bit helps.
posted by Mizu at 8:39 AM on February 24, 2010

Same thing happened to me -- nice polite periods became OH MY GOD STAND BACK SHE'S GOING TO BLOW AAAARRRRGH, to the point that I became very anemic. My doctor recommended a Mirena IUD, which I got a few months ago, and so far it's been great. She also had raised the idea of endometrial ablation.

You need a better doctor. One who will figure out if the Mirena could work despite your medical history, or else come up with a better plan. You shouldn't have to live like this.
posted by The corpse in the library at 8:48 AM on February 24, 2010 [2 favorites]

I'm in my 20s and I have always had horrifically painful periods that make me almost pass out from pain. Recently I've found that taking vitamins helps the pain quite a bit--omega 3 fatty acids, calcium, zinc, magnesium, and vitamin B. This won't do anything for the heaviness but it might make the pain more bearable.
posted by Lobster Garden at 9:06 AM on February 24, 2010

See an ob-gyn doctor. I kept thinking that the massive, heavy, ginormous-clots, wake up 2x per night to clean up the mess, pads + tampons periods were "part of getting older". I did not want to see a doctor about it because I was worried that the doctor would pat me on my head and tell me to man up, that heavy and oppressive periods were "normal" and "to be expected" as I aged. I worried about the jail term I'd have for strangling the doctor when he said it was all in my head. I waited rather a long time for things to get better on their own, all the while bleeding to my knees and being miserable for about a quarter of my life. Things did not "get better" on their own and I finally went to a doctor about it.

I had massive fibroids, to where I looked five months pregnant *all the time*. (You probably have something different, but it's important to be checked out.) For myself, I opted for a hysterectomy (kept ovaries), but that wasn't my only option. My point here is that there is probably something wrong and you will probably have some options for handling whatever your issue is.

Please see an ob-gyn for your specific complaint. All ya'll in the commentary who are spending roughly one quarter of your life bleeding to the knees and in pain and worrying about it and trying like hell to lead a life where other people can't see you drip blood all over the floor: See a ladyparts doctor. It is not noble or worthy to suffer in silence. Nobody is handing out merit badges for "lack of complaining about one's menstrual period"...

By the time I finally went to a doc, she was like "Okay, look. Too heavy is 'I change soaked super tampons every hour or every other hour for four days straight.' Too heavy is 'I wear tampons and a super maxi wings pad and I still bleed on the sheets three nights a month.' Too heavy is 'I can't be more than an hour away from a bathroom when I'm having my period. Ever.' If you plan your life around your period, it's maybe time to consider getting yourself looked at."
posted by which_chick at 9:25 AM on February 24, 2010

Clots, pain, messes - oh my gosh, this is me too, except mine just started, out of nowhere, a couple months ago. For the record, I've never given birth. I'm in the process of getting this checked out right now, so I thought I'd pass on the few things I've learned thus far:

Clots, and changes in bleeding patterns in general, can be signs of several serious things, including cancer. Get an endometrial biopsy if you haven't already had one.

The Mirena IUD, and progesterone-only pills, are not contraindicated in women with hypertension (that's me) - not sure if this is true for DVT or not? Something to look into. Some women get worse symptoms on these; some women stop getting periods at all (especially with the Mirena) - I have yet to try them firsthand as I'm still awaiting test results.

Endometrial ablation may be another option.

If your current doctor hasn't gone over all of this with you, do try to find one who will. I went straight to a gynecologist, bypassing my primary care doc entirely, and was amazed at how seriously this was taken.
posted by chez shoes at 9:27 AM on February 24, 2010

I second finding a more proactive OB/GYN for this. It never fails to stun me how abnormal periods are treated as an inconvenience and not a medical problem by many doctors. No one would tell someone with allergies to pollen to just stay inside all day during the worst parts of the season, yet that's more or less how many doctors treat abnormal periods. You should go in, lay out your medical history and every gory detail of what you wrote here to the new doc. If they don't know it's really interfering with your life, they'll just tell you to take half measures like more ibuprofen.

I think your situation calls for something more drastic; the options on the table should include trying Mirena, looking for fibroids, looking for endometriosis, or even a hysterectomy if all else fails and you're done with having kids. There may be more options beyond these; only a good OB/GYN looking at your whole history will know.
posted by slow graffiti at 9:54 AM on February 24, 2010 [1 favorite]

I have a personal history of elevated clotting factors and a family history of DVT / PE. I researched the Mirena _extensively_ and came to the conclusion that it was, in fact, beneficial for people with hypercoagulability. I had that thing put in, and my periods all but vanished. I didn't gain any weight, I didn't have horrible acne, I didn't have any of those side effects. I loved it and would get it again in a heartbeat.

Get a Mirena, is what I'm saying here. The hormone doses are so low they don't even register in bloodwork. Feel free to MeMail me if you want to know more about my clotting history.
posted by KathrynT at 10:43 AM on February 24, 2010 [1 favorite]

I had exactly the same thing for months, the same symptoms as you, and was told by a male doctor that it was just "heavy periods." I couldn't walk to the corner store without bleeding through two maxipads, and taking a hot bath was like a scene from Carrie. After I nearly passed out in the street and went to the emergency room, I finally got a diagnosis of a ruptured ovarian cyst and, later, endometriosis.

Please do get this checked out by an OB/GYN -- it isn't worth putting up with this crimson tide. Good luck.
posted by vickyverky at 1:10 PM on February 24, 2010

OH DEAR GOD IN HEAVEN IT PISSES ME OFF when supposedly qualified ladybits healthcare persons act like these sorts of periods are normal and women should just deal with them. HAIR ON FIRE here! CRAP MONKEYS!

okay, that's out of my system. another fibroids person here. they cropped up after three miscarriages, but my gynecologist didn't bother to look for them, even though they're one of the most common causes of abnormal periods so i just suffered through for almost a decade getting more and more anemic and despairing that my life would ever be normal again. after my gyn retired, my new one right away suggested ultrasound to look for them.

also, if that's what the problem is and you want to have more children, the fibroids themselves can often be removed, leaving the uterus intact, although any subsequent babies would have to be delivered c-section. the procedure is called a myomectomy.

whatever is the cause, please get this looked at and taken care of. you're just bleeding to death in slow motion here, no matter what the cause. i wish you the best of luck and good health.
posted by miss patrish at 2:19 PM on February 24, 2010 [2 favorites]

anastasiav: "Did your periods change radically post-childbirth?"

My mom likes to remind me that she had normal, medium periods until she had me at 36, and then she had to wear overnight pads all day and extra shorts under her pants so she wouldn't bleed through.
posted by IndigoRain at 3:58 PM on February 24, 2010

I am sorry you are going through this. I am not a doctor or a mother. I am in my early 30s and I understand your situation as I too have experienced horribly heavy bleeding which ruined my social life for a long time. Fortunately for me I was able to get things in control by taking BCs. I also second the infinity pads as they make life much easier.

Other home remedies that helped me was applying heat to the lower abdomen, which helped me relax and gave me relief from severe cramping. Yoga is generally good, however, there are some poses which are not beneficial when you have your period and I would do some research to avoid those poses.

I definitely second your getting a second opinion from an ob/gyn. Bleeding this excessive is not something you should have to go through on a monthly basis.

Best wishes and good health.
posted by VickyR at 6:17 PM on February 24, 2010

In a lifetime of awful periods I have discovered the most important thing is to take [your painkiller of choice (mine is Extra Strength Tylenol)] BEFORE the cramping gets bad. I also find pepto bismol helps with the cramping, because in me, at least, there is a strong intestinal component to the symptoms. I'm pretty body-aware, but it took me a while to 'get' that second connection.
posted by Ys at 7:07 PM on March 1, 2010