Question: I am a 58yr old woman, I have had no periods for approx.2.5 years. I am also overweight (BMI would rate me obese). April 2016 I had some very rare, minor spotting (dark colored, almost watery, with what appeared to be the odd pce of dark tissue or mucus). It was so minor I never even needed to wear protection, I only noticed it when wiping after urination. It disappeared after a few days but recurred a couple months later. I went to the doctor in August.
Transvaginal Ultrasound showed uterus retroverted, Myometrium mildly inhomogeneous with subtle sonolucent areas posterior mid body, no fibroid mass, subtle adenomyosis is not excluded. Endometrium 15mm in AP dimension at the fundus, no endometrial mass. Nabothian cysts present. Ovaries unremarkable with no masses, cysts or free fluid. Blood tests were good. Was referred to a GYN who did a pap test (negative for intraepithelial lesion or malignancy, benign reactive squamous cells present), a vaginal swab (negative for any infections) and an Endometrial Biopsy (Endometirum inactive, negative for Hyperplasia and malignancy). So all would look good. I still have the spotting. I have read that obesity and stress can cause this as well. This started in April for the first time and in February my job became extremely stressful and remains so. And of course, I am very stressed lately because of the tests, waiting for results, and so on. I also suspect Vaginal Atrophy, as I had noticed a change in the mucus (thicker and less of it) and a subtle itching when I spotted. I did not have good rapport with the GYN. She did the biopsy without ever explaining the procedure, risks, etc. which bothered me.. if I hadn't already done my research I would not have known a thing. She also prescribed me low dose vaginal Estrogen tablets. This was before the test results were back. I was to take them for about 3 months. I asked why and she said because if it stops we will know its Vaginal Atrophy. I do not want to start HRT of any kind unless it is really needed. She also never discussed risks, or ever said what symptoms would require me to seek help (either from the HRT or even after the biopsy).
My questions are :
1. After all these tests and their results, would I be safe to assume that it is obesity, stress, and/or vaginal atrophy causing this bleeding?
2. Is HRT such as this recommended usually? My research says it should not be used as a diagnostic tool and there are more risks for obese women.
3. If I did the HRT and the spotting stopped, would it come back even worse when I discontinued the HRT?
The spotting has continued, it worsened after the biopsy of course (for about 2.5 weeks) but was never bad. It still disappears for a few days then recurs but is still relatively mild. Perhaps a bit worse since the biopsy than it was. It seems to come on a little worse when I do physical work (I'm painting bedrooms).
Thank you.

Thank you for your response.
I did not note that I have had 2 children, both by C-section (no vaginal births).
I have also had the urinary 'urges' and increased frequency commonly associated with Vaginal Atrophy, plus I have not been sexually active with a partner in quite a few years. I also have the slight burning/itching of the vulva/vaginal area though it is mild.
With the test results in my GYN's office has not called me to come in for a followup (I can access my test results online which is why I have them) to suggest further testing such as you have mentioned here. I do not know if the visual inspection of the vaginal area added to a diagnosis of atrophy as she did not say. She did comment that the cervix was 'right where she needed it to be' and that it bled when she touched it for the pap test - something she said was not unusual with Atrophy. I would tend to feel from all of this that she felt Atrophy would most likely be the cause, perhaps something she saw, hence why she moved right to topical HRT. She prescribed vagifem 10 vaginal tablets but did say the cream was also an option.
From your response I have the feeling that you do not recommend starting the HRT until after a Hysteroscopy but I do have concerns about that test as it requires general anaesthesia which is something I do not handle well and am reluctant to risk unless there is a very specific reason to.
To clarify, there has not been a 'weight change', I have been this same weight for a number of years.
I don't really have another question but offer these additional comments in case they indicate anything else to you.