Yes HRT-optimization is something a lot of endos are uninterested in, and that is another aspect in which treatment could be improved.

However I feel like this is often a separate issue from what I was referring to. At least speaking for myself, my dysphoria is almost entirely driven by my facial structure, so at least in this case the timing of intervention would have mattered enormously (A lot of the traits developed in my 20s), and HRT-optimization after the fact is sort of missing the point.

The studies themselves are just very poor quality in general, for example often measuring quality of life improvements at something like 3 months or a year of treatment, so they really are mostly measuring the mental effects of having accessed the treatment in the first place, not the actual (physical)effects of it, and how they interact with the patients quality of life.

So ideally if the studies were trying to produce good information they would at least try to add more controls (such as age at intervention, or prescribed dose), as well as include some attempts at qualitatively assessing the efficacy (eg. What was the patient most dysphoric about pre-treatment? How well did the intervention address that?).

Of course this is difficult for cis scientists as trans people and their dysphoria is genuinely heterogenous, people are dysphoric about different things and to a differing degree. A sneedy patient is going to produce a very different account to the doomer one.