use of successive pharmacologic hormone suppression testing for a severe presentation of adolescent polycystic ovarian syndrome a case report background pathological causes of acne and hirsutism include polycystic ovarian syndrome pcos congenital adrenal hyperplasia and adrenal or ovarian tumors pcos is largely a clinical diagnosis and often simple laboratory testing can rule out more severe pathology in more severe cases determination of the correct diagnosis can require hormone suppression testing in this article we present a full sequence of hormone suppression testing and workup necessary to arrive at the ultimate diagnosiscase presentation a 12yearold normal weight body mass index 29th percentile premenarchal female with tanner iii breast tanner v pubic hair presented with a 25year history of severe hirsutism ferrimangallwey score of 22 clitoromegaly and deep voice successive hormone suppression and testing acth stimulation testing ovarian and adrenal imaging dexamethasonesuppressed acth stimulation testing and oral contraceptive therapy was necessary to rule out congenital adrenal hyperplasia or a tumor and confirm pcos metabolic testing completed only after diagnosing pcos demonstrated insulin resistanceconclusions this patient had an extreme presentation of a common disorder her premenarchal status elevated androgens and virilization raised concern for nonpcos pathology requiring sequential pharmacological hormone suppression testing and imaging for accurate diagnosis and appropriate treatment the testing presented here is not novel but we present the full sequence of testing and clinical results this full sequence is rarely necessary for accurate diagnosis given clinical presentation and initial evaluation and therefore to our knowledge has not been published all providers caring for patients with pcos should be familiar with this testing and its interpretation for severe cases that warrant extra attention