Does natural testosterone affect your skin differently than [testosterone] cypionate? I started getting acne in the last couple of months. I have been on a moderate stack of 100 mg [testosterone] cypionate and 100 mg of Deca [nandrolone decanoate] a week for the last year. I am turning 50 soon and use this for replacement therapy (prescribed). My doctor prescribed an additional 250 IU of hCG once a week when I commented that my wife noticed my testicles seemed smaller. Since then, I have broken out with pimples on my chest and back.

There is a push among some physicians to promote bioidentical hormone therapy. In essence, this would limit hormone replacement to non-esterified testosterone, estradiol, estrone, DHEA, pregnenolone, etc. Topical formulations aside, most forms of androgen replacement involve modified forms of testosterone, such as the injectable esters, 17alpha-alkylated oral forms, the oral ester Andriol^®, etc. There are several factors to consider in evaluating the equivalence of the various androgen therapies. Experiences with female hormone replacement and oral contraceptives have shown that non-bio-identical hormones have unintended health consequences in certain populations. However, these female hormone replacements involve changes to the estrogen or progesterone to make them orally bioavailable.
Nandrolone (Deca) is an altered androgen, so it is slightly different from testosterone in how it affects the body, especially non-muscle tissue, such as the brain, prostate, etc. The dose you have been prescribed, 100 mg/week, is relatively moderate and should balance well with the testosterone cypionate. Your total weekly androgen load of 200 mg/week of the esters is higher than many would prescribe, as treatment guidelines are quite conservative; however, it may very well remain within the physiologic range, albeit on the higher end. Some individuals are particularly sensitive to anabolic steroids, so it is possible that the testosterone/nandrolone combination you are being treated with is responsible for the outbreak.
The biggest differences between testosterone as an injectable ester and natural (endogenous) testosterone are the ‘pattern’ and the balance with the related molecule epitestosterone. Let’s deal with pattern first. Natural testosterone production and release is pulsatile, meaning it is released in ‘spurts.’ If you drew a graph of circulating (blood) testosterone concentration throughout the day, it would have around 6 to 10 peaks that drop off fairly quickly, bouncing back up with the next peak or ‘spurt.’

Long-acting esters like cypionate have one slow peak that goes up over a day or two and slowly drops, taking 7 to 10 days to reach the starting point or trough. It is unclear as to whether the pulsatile pattern offers any benefit to muscle growth or other androgen-dependent organs/tissues. Obviously, the injectable esters work well for bodybuilders and athletes for building muscle, though the onset of side effects is frequent among users. A short-acting nasal spray (Nasobol^®) is in development that would more closely mimic the natural pulsatile pattern, but the amount of testosterone that can be delivered by that route is limited. Clinical trials suggest that Nasobol^® may be effective for supplementing or replacing testosterone in hypogonadal men (men with low testosterone).
Epitestosterone is widely considered to be an inactive form of testosterone. It has been referred to as a failed product of the natural testosterone-producing pathway, but it is very short-sighted to think of epitestosterone in that regard. The body produces nearly as much epitestosterone as it does testosterone. If epitestosterone was just a waste product, that would be very inefficient and the body did not develop with such a high degree of waste.

Half of the circulating epitestosterone concentration is produced by the testes, but other sites of production account for the remaining 50 percent. When the testes are suppressed (stop functioning) due to age, testosterone replacement therapy, anabolic steroid use, or other reasons, roughly half of the epitestosterone production drops as well. If testosterone (or anabolic steroid) concentrations are then replaced by the drugs which do not include an epitestosterone component (with the exception of doping formulas such as ‘the cream’), then there is an imbalance between the androgen-stimulation and the anti-androgen effect of epitestosterone. The results of this imbalance may include hair loss, acne, and possibly mood changes.
As with most drug therapies, the degree of sophistication has not yet been reached to perfectly mimic the natural events.
You mentioned noticing the acne after starting hCG. The use of hCG in conjunction with (at the same time) testosterone or other anabolic steroids is fairly recent. Prior to the mid-‘80s, most bodybuilders (the most obvious ‘test’ group) did not use hCG until they had completed an anabolic steroid cycle. The purpose of hCG was to stimulate natural testosterone production after a prolonged period of testes suppression and atrophy (shrinkage). Bodybuilders believe the use of hCG accelerates natural testosterone recovery, minimizing the risk of muscle loss, depression, etc. Anabolic steroid cycles have become more aggressive and prolonged to meet the demands of black market consumers.

It is not uncommon for many anabolic steroid users to find that ‘standard’ hCG treatment does not adequately stimulate the testes to recover from cycles that may extend over a year or longer, with weekly exposure surpassing 2,000 mg testosterone equivalent per week. To avoid complete or irreversible testes atrophy, many extreme anabolic steroid users are using hCG during a cycle. The result is not long-term recovery, but maintaining limited testes function during a long-term cycle so that it can respond more vigorously to post-cycle recovery.
Most look at hCG as a benign drug, but it carries the risk of side effects, just like every drug. Among the more commonly experienced by males is acne. Given that your outbreak occurred after you started hCG and did not arise earlier when you were using the testosterone cypionate and nandrolone decanoate, the logical conclusion is that the hCG tipped the scales. Remember, acne occurs in many anabolic steroid users, even at replacement dosing. You should discuss this with the physician who prescribed the hCG to you and let him/her know of your concerns. It would seem prudent to discontinue the hCG and continue to treat the areas affected by the acne with a benzoyl peroxide-containing soap or cleanser. If the condition does not clear in a matter of two to three weeks, notify your physician or request a consult with a dermatologist.

I managed to get some insulin to add to my stack. I know a couple guys who used it and they put on 20 pounds in about six weeks. They weren’t real clear about how to use it and my girlfriend who is in nursing school said people can go into a coma if they don’t use insulin right. How do I use this stuff?

The right answer is: you don’t. There is not a single physician who can ethically offer to prescribe insulin in any form for the purpose of performance-enhancement or building muscle. Your girlfriend is correct, but does not fully state the dangers involved with the misuse or abuse of insulin. Incorrectly dosed, insulin can drop blood sugar (glucose) levels so low that the brain is unable to compete with the rest of the body for the sugar it needs to supply its energy needs.

The condition of hypoglycemia (low blood sugar) is similar to the problems ‘normal’ people have when they experience ‘low blood sugar’ either after a heavy meal or a long period without food; irritability, confusion, impaired ability to perform calculations or make decisions, etc. However, in the case of an insulin ‘overdose,’ the brain can shut down until only the most basic life support functions are maintained (breathing, heartbeat). In the most severe cases, even these most basic and vital functions fail and death can occur.

Every year, diabetics are admitted through the emergency room, due to insulin dosing errors. Deaths have been thankfully rare. Insulin has even been used as a murder weapon or as a means of committing suicide.
You do not want to mess around with insulin. Why then do some people use insulin? Insulin is an incredibly potent anabolic, though it is not [relatively] specific to muscle as anabolic steroids. Though its net effect is anabolic, in muscle, it functions more as an anti-catabolic. Athletes, especially endurance athletes, consume a considerable portion of carbohydrates after training. This serves two functions: it replenishes glycogen (a stored source of sugar in the muscle), and stimulates an insulin spike, which also stops the breakdown of contractile proteins in muscle, as well as any remaining glycogen.
Power athletes, including sprinters, began using insulin to maximize the anabolic effect of training by blocking the breakdown of contractile protein in muscle. Power training does utilize muscle and liver glycogen, but rarely depletes it in an athlete who is not on a carbohydrate-deficient diet. So, the sole purpose of using insulin in this setting, which closely resembles hypertrophy-based weight training, is to promote muscle anabolism by minimizing the exercise-induced catabolism.
Athletes have learned that insulin has to be carefully dosed and timed with the ingestion of carbohydrates. Also, the form of insulin chosen needs to be selected judiciously as some are slow-releasing, which does not provide the profile desired by athlete-users; others are very rapid, some are blends. Anecdotal reports suggest that even athletes willing to embrace high-risk behavior are very cautious when beginning insulin use. William Llewellyn reports that 10 IU of short-acting insulin is the most common dose used immediately post-workout; many start at 2 IU and work up slowly.
Those looking to use insulin to improve the physique need to be aware that insulin also promotes fat storage. A hypoglycemic episode can come on quickly; automobile accidents have occurred in diabetics following their usual prescribed dose. Another risk comes from the method of administration. Even though insulin is injected just under the skin, it can still introduce bacteria and establish an abscess. In short, those who do not have training or a significant experience base must not use insulin. The risks are high and may be life-threatening.