I have not had periods for about eight years. Five months ago, I had one normal period, and then for three months I had spotting. I want to get pregnant, so my gynecologist has given me a prescription for Provera and Clomid. Is this really the right thing to do? I fear that the child would be abnormal because of the drugs, or because I don't get my periods. Should I just wait until my period comes? Is there anything I should do to find out what's causing the problem? Or should I just go ahead and take these pills?

W.G.

Treatment with Provera and Clomid without an evaluation is not appropriate. It's true that Provera may well bring on a menstrual bleed, and Clomid may help you ovulate -- and there is no reason to believe that either may increase the risk of fetal anomalies. However, treatment without an evaluation may lead to unnecessary, potentially avoidable pregnancy complications.

Many physicians will prescribe Provera and tell patients that it will "jump-start your periods." Unfortunately, the hormonal system is not like a recalcitrant Ford. You can't just jump-start it to wake things up. When you don't ovulate, many different types of problems may be involved. I can't begin to guess why you are having problems with your menstrual cycles. It may be due to age, thyroid problems, obesity, pituitary or hypothalamic problems resulting in hormonal imbalances, ovarian failure, uterine problems, polycystic ovary syndrome, diabetes, stress, exercise or anorexia, for example.

This is something you and your doctor need to investigate. Are you suffering from age-related infertility? Are the hypothalamus and pituitary secreting the appropriate hormonal stimulation to bring about development of the ovarian follicle? If tests show your level of the hormone FSH is too high, ovarian failure may be indicated. If pituitary FSH secretion is low, factors such as tumor, stress, exercise and diet may be involved. Most often no obvious cause of hypothalamic pituitary disturbance can be found.

The next step in our investigation is to determine if the ovaries appear to be working. If the ovary receives the FSH signal, the follicle should grow and make estrogen to stimulate growth of the uterine lining. If estrogen has stimulated endometrial (uterine lining) growth, Provera can bring on a menstrual period about one to two weeks after the last tablet. So, if there is bleeding after Provera, we know that the ovary is capable of responding and has been secreting estrogen. If there is no bleeding after Provera, then either the hypothalamus and pituitary are not signaling the ovary to do its stuff, or the ovary is just not listening to the hormonal message from the FSH, indicating ovarian failure.

If the FSH is normal and there is no response to Provera, we must also consider if there is a problem with the uterine lining. A condition called Asherman's syndrome or intrauterine adhesions (rare scarring after a D&C) may result in absent menses. Anatomical abnormalities present from birth, such as the absence of the uterus or upper vagina, may also prevent normal menses despite the appropriate hormonal patterns.

At a minimum, your doctor should consider testing you for thyroid dysfunction, excessive male hormone levels, and FSH levels. You should also be asked to begin a prenatal vitamin before attempting pregnancy.

A semen analysis for your partner is mandatory before initiating any hormonal treatment for infertility. Unfortunately, all too often I see women who have been on clomiphene for six to 12 months whose partners were never tested, and who later learn that their partner had a severe fertility problem.

It sounds to me like you deserve better care. I would strongly recommend that you consider consultation with a fellowship-trained reproductive endocrinologist who will perform a comprehensive evaluation. Treatment without performing even a limited number of tests is just not appropriate care in this day and age.